Nursing needs its leaders to respond to FrancisPractice blog
Does anyone remember when patients made the hot drinks?
When I was a student we used to ask patients to do the milky drinks rounds in the evenings.
Those were the days - when patients stayed in hospital until their stitches came out and we worked in predictable peaks and troughs with the occasional crisis. Life was less complicated 30 years ago. Patients trusted their nurses and there was never an expectation that anyone would complain.
The challenges faced by nurses today are so much more complex. Even if you had a patient well enough to do the hot drinks, they would probably not be allowed to help for health and safety reasons. The pace of change is rapid and it feels as if nursing has failed to keep up and engage the implications of this change.
We need to have that tricky conversation about what nursing is, what is driving its development and whether a direction is right for patients’ care. An example might be 12-hour shifts. They save money and might be good for staff arranging child care or social lives, but are they good for patient safety?
Marie Manthey, the advocate of primary nursing, gave some great advice that I always used when considering any change in practice: “Patients matter most but staff matter too.”
The new CNO of England, Jane Cummings, has laid out her vision for nursing and underpinned it with values: care, compassion, courage, commitment and communication. It is easy to be cynical but I think she has captured, in those five words, what nursing is.
She has started a dialogue about what nursing is and it is up to the profession, at all levels, to engage and take up the debate. This appears to be a real opportunity to talk about what nursing really means and define a philosophy for the future.
Imagine every nursing team across England sitting down for an hour and using the ‘five Cs’ to carve out their philosophy of care. An hour to write down what nursing means to them on their ward, unit or department and how they can achieve their goals. There is power in being able to articulate why your work is important, why it should be valued and to celebrate what you do well. It also helps to clarify when concerns should be raised and where change needs to happen.
Nursing has to change at grass roots level - anything else is merely cosmetic. So let’s stop talking audit and dashboards for a minute and think about what nursing should be. What is the value of empathy, compassion and care? How can nurses provide the best care all day, every day? What are the limits of nurses’ roles? What do patients actually need and want from nurses? When do nurses make a difference?
Being clear about what drives and motivates you and feeding this into the national debate is vital for patient care. With clear vision we can recapture public respect, but more importantly, their confidence in what we do.
'Patients who put nurses before themselves need putting straight'
An elderly woman said to me recently that she wore incontinence pads because it was easier for the nurses.
She needed to be hoisted in and out of bed so had to ask two nurses to use the hoist to put her on the commode or toilet. However, she said that she did know at least half of the time that she needed to use the toilet so with support and reassurance from the nurses could have maintained her dignity by using a commode or toilet.
Patients who are in hospital for a long time or who are being cared for in a nursing home can lose sight of their rights as an individual as part of being institutionalised. They start to put the nurses before themselves and try to do what they think the nurses find easier. Maybe it’s in some way like a prisoner trying to please their captors. And who wants to be unpopular with the people you depend on!
Ward and nursing home routines can rob the individual patient of their autonomy. However, nurses can try and find flexibility where they can to allow and encourage the patient to be an individual. If a patient likes to stay up late watching TV, nurses can position and settle them later rather than doing so just because the clock says that it is time.
Patients who have previously been independent do find it hard to accept that they need assistance and have to ask for help. Reassurance from nurses, that the assistance they offer is their job and that the patient is entitled to it, will need to be offered regularly. Nurse can help patients find their way by treating every patient differently because let’s face it, they are.
'Nothing in nursing is really simple; comprehension of its complexity is vital'
After all, if they did understand the implications of diabetes insipidus they should have been able to give Kane the care he needed. If not, they had a responsibility to get the information they needed to ensure his care was safe and effective.
When a student, I was told never to give a drug unless I knew the indication, contra-indications, side effects and normal dose; the same went for understanding a patient’s diagnosis and treatment. Indeed, if you don’t truly understand what is wrong with your patient - the underlying anatomy, physiology and pathophysiology, then how can you look after them? Without this knowledge, nursing is nothing more than tasks - and tasks without understanding are dangerous things.
Which brings me to skill mix. Recent data from national nursing research unit suggests the average proportion of registered nursing staff - compared to unregistered healthcare assistants - on day shifts is 56%. This places the onus on the registered nurse to ensure that HCAs carrying out day to day care, such as fluid management, understand the significance of patient diagnosis. This is probably easy when staffing is stable and patients are on appropriate wards, but what happens to patients who have multiple and complex conditions?
It is often claimed in the media that anyone can give someone a drink but it’s not “simple” for someone with diabetes insipidus. Anyone can wash someone but it takes a bit more thought if a patient has a fractured neck of femur. Anyone can help someone to eat but not if they have dysphagia. Nothing in nursing is really simple which is why delegation has to be managed carefully and nurses given time to ensure those giving care, who often are not nurses themselves, understand the significance of what they are being asked to do.
'The time that students offer to patients can be invaluable'
In this time of stretched resources and staff cuts, student nurses can provide an extra element of care for patients.
I was watching a student nurse recently carrying out mouth care and her inexperience and nervousness about this new skill meant that she carried out the task carefully and slowly.
The patient was obviously enjoying the attention and slower pace of the care. The student nurse grew in confidence and had made a good relationship by the end of the procedure.
Student nurses are a valuable resource and often have a little bit more time to offer patients which they will value. And although they move around they become recognised members of the hospital staff.
My mother recently went back into hospital and greeted a student nurse that she had met on another ward a few months earlier like an old friend.
Student nurses are invaluable members of the team who although inexperienced can offer time and a different dimension of care.
We celebrated the importance of student nurses in our first Student Nursing Times Awards – an event that was so uplifting and reassuring about the future of nursing that we are already planning next year’s event.
'Whistleblowers need a supportive stance to be reflected in UK law'
The recent news that pharmaceutical giant GlaxoSmithKline had received a record-breaking fine for fraud grabbed my attention.
The company admitted to offering doctors regular golf lessons, fishing trips, and basketball tickets while promoting the use of an antidepressant drug for use in children - a use for which it was unapproved. It also and failed to report safety data about a diabetes drug, as well as improperly marketing other drugs. As a result, it was fined an eye-popping $3bn.
As I listened to the story I felt a familiar mix of anger and resignation that wells up when the increasingly frequent examples of corporate misbehaviour hit the headlines. But then the story took another turn, which really piqued my interest.
The illegal activities came to light because an employee blew the whistle. Greg Thorpe raised concerns over the ethics of the company’s business practices with senior managers back in 2001. He was forced out of the company for his pains. So far, so familiar.
But the story didn’t end there - Mr Thorpe took his concerns to US regulators. And far from burying the issue, they spent 10 years getting to the bottom of the story. And here’s where Mr Thorpe’s story differs from those of so many UK whistleblowers. In the US, whistleblowers receive a share of any money recovered by federal government as a result of their disclosures. Yes, you read that correctly - in the US you can actually benefit from bringing to light corporate lawbreaking.
How different from the UK, where whistleblowers are routinely harassed, maligned and disciplined, many having their careers blighted and their mental health destroyed - and often for raising concerns that do not even involve lawbreaking but simply practices that need to improve. If they do receive any money it is in the form of a gagging clause to ensure their information does not reach the public domain.
Yes, Mr Thorpe lost his job, but at least the law in the US takes a more supportive stance towards whistleblowers. Perhaps if we had a similar law here in the UK employers would feel less inclined to protect themselves by destroying the credibility of whistleblowers, and more prepared to learn from the valuable information they disclose.
'It can be hard for acute units to change their mindset to care for the dying'
A report has found that relatives and carers are less satisfied with the experience of having a loved one be cared for in an acute hospital setting than in a hospice or at home.
The DH commissioned survey found that bereaved family members found that 87% of doctors and 80% of nurses in hospices showed dignity and respect “all the time” but that in hospitals this fell to 57% for doctors and 48% for nurses.
Marie Curie Cancer Care and National Council for Palliative Care and the Dying Matters Coalition rightly call for better end-of-life care and express disappointment that increased training has not improved care.
Sadly the reality is that the dying person will be unlikely to receive the same quality of care in the acute setting as they do in a hospice but there is a reason for that.
Hospices’ work is focused on and dedicated to the physical, emotional, spiritual and social needs of those with a life-limiting or terminal illness. Acute units are dedicated to preserving life and striving to get patients well enough to be discharged.
As a result it can be hard for acute units to change their mindset to care for the dying. Acute units are busy noisy places that are struggling to provide the level of care they aim to with the current level of resources.
It can be hard for staff working in acute care to accept that a patient is not going to survive. Nurses can feel that they have ‘failed’ and so they can be reluctant to redirect the energy of their work away from preserving life to ensuring that a dying person is comfortable.
Surveys like these should not be used to criticise staff for their shortfalls but should be used to enquire why the system is not working. Issues such as these are generally a system failure not that of individual staff.
Hospital nurses need support and resources to be able to offer end-of-life care as it requires significant skills offer to such care within the often frenetic life that is the acute ward.
'When I first heard about the family and friends test I was sceptical'
Last week my new neighbour asked if I could recommend my GP practice.
Yes I did recommend it but the recommendation came with clarifications about which GP was good with children, which one listened and which was quick if you had something fairly straight forward. Not a simple “yes” or “no” answer.
Currently the NHS is asking patients whether they would be happy for their friends and family to be treated by their service in a test which will be used to compare trusts’ performance. These so called net promoter scores are used in the independent sector to measure the quality of services in competitive industries.
When I first heard about the family and friends test I was sceptical. Is it possible to measuring satisfaction with healthcare in the same way as buying a tin of baked bean or getting my car serviced? My scepticism was confirmed last week when research raised doubts about the “friends and family” test as a single indicator of patient experience.
The research published by the Picker Institute Europe and Care Quality Commission found that people didn’t understand what they were supposed to be recommending, and “some interviewees gave high scores despite describing very poor experiences to the interviewer”.
Researchers did find one question which worked well, in which patients were asked to score their overall experience of care from “0 (I had a very poor experience) to 10 (I had a very good experience)”.
It seems to me that NHS is continually searching for new ways of asking people about their experiences of healthcare. But why roll out a scheme like this and then do the research to find out if the right question is being asked?
Front line staff need to know how they are doing and if they are getting it right for the people in their care. Net promoter scores tick the box labeled consumerism but considerable time and effort goes into collecting this information and if we are asking the wrong questions the information is useless both to patients and staff.
'We all make assumptions about our patients and their relationships'
Many years ago I nursed a man, Jim (not his real name) who was a widower.
He had a few visitors, a couple who lived next door, an old friend called Pete (not his real name) who came every day and his daughter visited at the weekend.
Jim had a series of complications following an MI and his condition suddenly deteriorated one evening. His daughter was called and over the next few days it became clear that he was going to die.
The day after he collapsed his old friend popped in. Pete was in fact his partner and they had been in a relationship for many years but had kept it a secret from their families for fear of their reaction.
What followed was a very difficult situation. As Jim deteriorated his daughter sat with him and Pete continued to play the role of concerned friend. He told the nurses how they had been part of each others lives for 20 years but at the end he was not able to sit and be with Jim or take any part in his funeral arrangements.
The nursing team found it difficult to balance the need for secrecy with the need for Jim and Pete to spend time together. We did our best but we knew that when Pete left the ward he would grieve on his own.
Last week the National End of Life Care Programme published guidance on care for lesbian, gay, bisexual and transgender people at the end of their lives.
While guidance cannot change societal attitudes it can help healthcare staff understand and respond to the challenges faced by a person has not previously “come out” or those isolated from their families because of their sexuality.
We all make assumptions and judgments about people and their relationships: the family who never visit, the wife who bullies her husband and stays too long, or the person who has no one who cares about them. These guidelines challenge us to examine our attitudes to relationships and what we understand by the term “next of kin”.
Sam Turner, director of public engagement at the National Council for Palliative Care, sums up the consequences of failing to do this. She says: “We only have one chance to get end of life care right for people who are dying”.
For Pete and Jim the fear of being “found out” and of rejection surpassed their wish to spend their last days together and that is profoundly sad. We couldn’t fix their problem but perhaps with guidance we may have had more understanding and the confidence to support Jim and Pete and ultimately make their lives easier.
Why are nurses still afraid of opioids?
Nurses’ understanding of pain treatment is essential for its effective management. Yet effective pain control often eludes those who most need it particularly when opioid analgesics are involved.
Last month NICE clinical guideline on prescribing opioids to relieve pain was published. It highlighted that up to two-thirds of people with cancer that experience pain need strong opioid and the number is similar in many other advanced and progressive conditions. Yet pain remains under-treated in these groups of patients.
Opioids, especially morphine are vital drugs in our treatment of pain but the public and many health professional misunderstand and misinterpret their use. Myths surround morphine: it is often viewed as a drug of last resort for those who have no hope. We have all seen relatives shake their heads and whisper “They’ve started him on morphine” or met patients who tolerate pain and pride themselves on resisting their opioid medication because they do not want to become addicted. How many nurses believe you can’t give opioids to patients with COPD? Yet they are vital drugs in the management of breathlessness at the end of life.
The Harold Shipman case has left its mark on how prescribers view opioids and I wonder if fear of scrutiny has resulted in an over cautious approach or avoiding prescribing opioid drugs at all. Yet these anxieties should not exist in a health service that has considerable expertise in pain control and palliative care. All health professionals should be able to access this expertise and be confident in their understanding of pain, the drugs used to treat it and their ability to communicate this to patients.
The new NICE guidance highlighted the vital role nurses have in demystifying opioid analgesia for patients and ensuring they understand the benefits and side effects of treatment. To do this, nurses need to challenge their own beliefs and anxieties about these drugs and ensure they approach this vital part of care as knowledgeable practitioners.
'When we see a patient’s condition deteriorating, the instinct to save usually kicks in'
The only way health professionals can be sure of spotting it is if initial assessment on admission is thorough, and is repeated at appropriate intervals. It is also important that all members of the healthcare team are clear about what treatments or interventions are appropriate.
The latest publication from the National Confidential Enquiry into Patient Outcome and Death reports on the care received by patients who received CPR after a cardiac arrest in hospital. NCEPOD found that in almost half of cases the patient’s initial assessment was deficient, and that senior doctors were not involved in managing many of the patients.
While a variety of reports have made recommendations on how to respond to patient deterioration, this one also identified the need to focus on those patients whose best interest may not be served by initiating CPR or life-prolonging treatment. This may be the case even in patients who are receiving active treatment to try to improve their condition.
When health professionals see a patient’s condition deteriorating, the instinct to save usually kicks in. However, when patients are dying, CPR is inappropriate and can make their last hours painful, distressing and undignified.
Thorough initial assessment of acutely ill patients is crucial, but should also include assessment of whether or not this patient should be resuscitated in the event of cardiac arrest. Of course decisions not to attempt CPR should not be taken lightly. They must involve senior doctors and, if possible, the patient and/or next of kin - which must be done with care and sensitivity. Once taken, however, DNACPR decisions must also be respected.
Acutely ill patients are extremely vulnerable if their condition deteriorates. They deserve thorough assessment and observation to ensure the care they receive is appropriate to them - and sometimes that means stepping back, keeping them comfortable and letting nature take its course.
'It's too easy to forget the simple things that make a big difference'
Looking out of my window at the garden on a lovely sunny day reminds me of my Dad. He loved the summer, sitting in the back garden with my Mum.
I remember the last summer he was alive. His walking had deteriorated and his Parkinson’s and chest problems were catching up with him.
We got him out in the garden and he sat under the blackberry brambles catching the branches with the hook of his walking stick so my two boys could pick off the berries.
We were in t-shirts but he felt cold and was wearing a jumper, jacket and hat but I remember him looking up and saying how lovely it was to have the sun on his face. I knew then he probably didn’t have another summer, and I think he knew it too, but by then he had learnt to appreciate the small pleasures life offered.
Last night I was chatting to a friend who works in a nursing home and she said the biggest challenge this week will be ensuring everyone in the home stays hydrated. The drinking challenge is on.
It made me think about all those people confined to the inside of nursing homes or their own homes, unable to enjoy the benefits of a sunny day without the help of others. People who don’t get to feel the sun on their faces because there isn’t time to get them up and out.
By virtue of staffing levels and workload we often have our heads down dealing with the physical needs of the chronically sick and those with disability, and it is easy to forget that the simple things make a big difference.
It takes a bit of time and organisation but it is possible.
Yesterday, as my son and I walked to the shops to buy ice-creams, we passed a group of carers and people with learning disabilities doing the exact same thing.
We were all sharing the same pleasure and anticipation that an unexpected sunny evening brings, and if we need a clinical focus for this blog, we were topping up our vitamin D levels at the same time.
'Hiving off important responsibilities devalues nurses' skills'
News that a West Midlands trust is to extend a scheme whereby unemployed people deliver patient care makes me deeply uncomfortable.
First there is the issue of whether it is right to be asking jobseekers to spend eight weeks doing unpaid work in an NHS that is shedding staff. I appreciate that many unemployed people need support in their search for work, and being able to show relevant work experience can make all the difference to job applications.
While Sandwell and West Birmingham Hospitals Trust may not be using unpaid workers to undertake work previously done by paid staff, there is certainly the possibility for trusts to consider this as a way of filling gaps left when staff numbers are cut.
I also have misgivings about the type of work the jobseekers are being allocated. While many of the tasks are uncontroversial - general tidying, welcoming visitors, running errands, and reading to patients – they are also being asked to serve drinks to patients and assist with feeding.
Ensuring patients receive adequate nutrition and fluid is a fundamental nursing role, and in the reports highlighting poor standards of care over the past couple of years, nurses have been repeatedly accused of failing their patients in this respect.
The profession has been accused of being more interested in academic qualifications than in core nursing responsibilities, yet fluid and nutrition are suddenly the domain of those undertaking unpaid work experience.
Hiving off these important responsibilities devalues nurses’ skills and puts patients at risk, yet nurses will still be held accountable if anything goes wrong, because they will be delegating the tasks to the unpaid workers.
Nursing has come in for a huge amount of flak recently, and the poor practice of the few has been used as a stick to beat the many. How is the profession ever to put its house in order if it is bombarded with mixed messages about its key responsibilities?
'We need more health visitors AND more district nurses'
The recent report on community nursing released at RCN Congress highlights the pressure that community nursing is currently under.
Falling district nurse numbers, social care cuts, and an ever growing number of increasingly complex patients. It’s a frightening mix and with a significant number of district nurses set to retire in the coming decade, it’s hard to see that others will be rushing to step into their shoes.
It’s already a tough job without all the increasing pressure currently being loaded on. Working in a ‘hospital without walls’ is a challenging role. Making decisions about frail and elderly patients with multiple co-morbidities in their own home takes skill and training. There is no second opinion readily at hand – you are on your own with limited resources. While nursing support workers do a great job in working alongside registered nurses in the community, the complexity of the work means that the ratio of registered nurses and support workers must not swing too far in the wrong direction.
The push to increase the numbers of health visitors is welcome. However this campaign is more likely to recruit from the community nurse workforce as those already working in the community are more likely to apply. For those working in hospitals, it can be a leap of faith to take that step to work outside the hospital environment that they are used to.
Also the increase in health visitor numbers must not be used as a panacea for the fall in district nursing numbers. I was struck by how Andrew Lansley answered a question about declining nos of district nurses at RCN Congress by talking about the increasing number of HVs. A good initiative but it’s not the same thing.
The RCN report makes clear for the urgent need for more district nurse numbers and support for this crucial arm of the profession. Lack of support and care of patients in the community will inevitably lead to more hospital admissions. It feels like we are just going around in circles. Policy makers need to wake up to the fact that all the money comes out of the same pot so cuts in the community will lead to increased costs in hospitals.
'How can you revise if you don't have a plan?'
Along with “What biology coursework is now on You Tube?” and “How can you revise when your physics book is downstairs?” Sadly my daily lecture on the benefits of a plan, to-do lists, colour pens and PostIt notes is greeted with, at best, rolling eyes and a “whatever”.
The ongoing debate about revision plans reminded me of the debate in nursing about the value of documentation.
Is it possible to start work without a plan of what you are going to do? Yet a news story last week highlighted the enormous amount of work nurses have to leave undone because of staffing levels.
One of the tasks frequently omitted was the planning and documentation of care: 47% said they failed to develop or update care plans; 33% failed to adequately document care; and 28% failed to complete care plans.
The test of a good care plan is that staff, at a glance, can identify what has been done before, if it was successful and what is planned for the future. I remember working with a ward sister who advised staff to read the care plan first and then ask questions. She believed a good care plan should save time rather than make work.
Yet many of us have a dysfunctional relationship with documentation. It is viewed as an add-on, often completed after the work is finished in the office over a cup of coffee. The quality and quantity of paperwork is a barrier to completing it and incomplete documents have little practical value for day-to-day work, so no one looks at them or trusts the content. Sadly the value of good documentation is often only realised when records are used as evidence in court.
I would argue that a patient’s written care plan is pivotal to providing personalised care and there needs to be a radical rethink of how this happens in practice.
Clinical staff must be involved in the design and content of documents so they are clinically useful. The temptation to add in another assessment or tick list to meet a new directive or target needs to be carefully considered.
Nursing documents should be owned by individual patients and the nurses caring for them. They should be dynamic description of patients’ wants and needs, how these can best be addressed and the progress patients are making. If this is the focus, nursing documentation will become a valuable and essential part of care. But if this is to happen, the most important requirement is that time is made available and staff are supported to ensure this essential part of care is completed.
'We must recognise when medical intervention is inappropriate'
One parent has cancer, and has been on the Liverpool Care Pathway for weeks. She and her family have received excellent care and support, which has focused on keeping her comfortable and offering emotional and practical support to her and her loved ones.
Of course they are all finding this period difficult, but my friend told me that the team caring for his Mum has enabled the family to find pleasure in their remaining time together. She is comfortable and able to satisfy herself that she is attending to things that are important to her, while her family are reassured that any distressing symptoms will be addressed promptly by professionals who understand end-of-life care.
My other friend’s Dad has advanced dementia and is now frail and declining before our eyes. He is in a nursing care home yet he has been taken to A&E twice in the past couple of months, and then admitted to hospital where he has had arterial blood gas analysis and aggressive antibiotic treatment which was distressing for him and therefore his family. After the first trip to A&E my friend asked the home not to take him in again. She understands that he is dying, and that heroic interventions simply prolong a life that is devoid of any pleasure, yet he was taken in a second time and the process was repeated causing the same levels of distress to all concerned.
These two situations reminded me of a paper at last week’s RCN Research conference, in which Karen Waters reported on a study of the end-of-life care received by patients with dementia. Like my friend’s Dad, 78% of her retrospective sample received burdensome interventions.
Like my first friend’s Mum, many people with cancer or other diseases that are recognised as being potentially terminal receive excellent end-of-life care that gives them both physical and emotional comfort and supports their family. No one tries to “save” them because it is accepted that this is both inappropriate and impossible. Shouldn’t those who are simply reaching the end of their life be able to expect the same?
Some details have been changed to protect confidentiality.
Trolleys as beds: how have we come to this?
You realise what trouble we are in when policy advice is being given on whether it is best to look after patients on a trolley in A&E or on a trolley in a ward corridor. We seem to have got past the point where either of these situations are unacceptable and are now being seen as inevitable.
The advice last week from the College of Emergency Medicine is that this is the safest way of dealing with current capacity problems in some hospitals.
Maybe so but we have to careful that we are not setting up a system that will become the norm ie that every 20-bedded ward will now become 20 patients plus the one unfortunate on the trolley.
Apparently there is substantial evidence patients are harmed waiting in overcrowded emergency departments or ambulances but there is no evidence of harm to patients through waiting on wards. It may be of course that once a significant number of patients do end up on trolleys in ward corridors that we will establish that that causes harm too.
Ward corridors can be frantic and frightening places. Any patient parked in a corridor will get a ringside view of what is happening throughout the ward, much of which will appear alarming. Ringing phones, harassed staff, ringing buzzers, distressed relatives. It will all be on view and I can’t imagine it will be good for their health and recovery.
The college does specify that the patient stuck on the trolley must be “stable, orientated and not receiving active treatment or require monitoring”. However it won’t be long before that detail is lost and the trolley be treated like the 21st bed. The college may be giving useful advice — the worry is how it will be used.
'Nurses have to knowingly carry out detrimental bed manoeuvres every day'
Listening to recent news reports on discharge from hospital at night I wondered where were the nurses representing the needs of a 94-year-old man sent home at 1am in the morning.
The Times news story and the data it was based on was flawed, but it did make me think again about what it really means to be an advocate. Is it possible to represent your patients if you have no power to influence or change their circumstances?
I was reminded of a time - when I was working as a bank nurse at a large teaching hospital - I was asked to transfer Mr Jones, who had dementia and visual impairment, from an acute medical ward to a surgical ward at around 12.30am.
He was one of the great number of “unwanted patients” in a busy hospital pushed for beds. His medical treatment was complete and but his long-standing health problems meant he needed a bit more time to get his social situation sorted before he was discharged home. As I pushed him through the empty corridors he asked time and time again where we were going and as we got to the surgical ward his distress was tangible to the staff who greeted him.
As I told the surgical nurse about his problems I could feel her anger growing. She shared my distress about moving this frail and vulnerable person from a ward where he had become familiar with his environment and routine. Yet we were both powerless to prevent it happening.
When we were told to move Mr Jones I asked the bed manager what would happen if we refused to. She replied: “We will just get someone else to do it”. Down in A&E someone needed an acute medical bed and Mr Jones lost out.
Bed manoeuvres happen every day in hospitals and I suspect many nurses have had to push patients to other wards knowing that it will ultimately be detrimental to their wellbeing.
So where does this leave nurses as advocates? Should they think about the needs of the person waiting for the bed or focus exclusively on their patient? The NMC advises “Advocacy is concerned with promoting and protecting the interest of people in the care of nurses and midwives, many of whom may be vulnerable and incapable of protecting their own interests”.
But how do you do this in a system that is so pushed and underfunded that it demands nurses compromise the needs of patients in their care for the greater good of those elsewhere?
'The battle for nurse representation on CCG boards isn't over'
After all, who would ever assume the bulk of NHS care commissioning could be done effectively without the involvement of the largest group of health professionals.
Except it wasn’t a no-brainer was it? What are now CCGs were originally to be GP commissioning consortia, and there was no requirement for GPs to involve nurses - or any other health professionals for that matter. As a result of pressure from many quarters, including our own A Seat on the Board campaign, the government came up with a less contentious name for the consortia and made it mandatory to involve other professionals.
So now the NHS and Social Care Act has passed into law, and like it or not, health professionals have to make it work for the good of their patients. But it seems the battle for nurse representation on CCG boards isn’t over. As we revealed last week, CCGs will not be allowed to take on their duties unless they have a nurse on their board - but they are free to design the nurse’s role, and there are wide variations in the status of nurses on CCG boards.
Most health professionals agree that making the new NHS work is going to be difficult at best. But if nurse involvement on CCG boards is just a token gesture, it will be nigh on impossible. It took years for hospitals and trusts to accept the value of appointing directors of nursing in the first place, and even longer for them to see the value of making them board members. Surely the profession isn’t going to have to fight the same battle all over again with CCGs. If commissioning is to be led by health professionals then the ones who spend most time with patients and look at them from a holistic perspective must be fully involved in the process.
'Our nurses are burnt out but still offering good care'
It was probably not much of a surprise to nurses out there on the frontline that their experiences are nearer to those of nurses in Greece, a country facing economic meltdown, than nurses in countries we would feel more usually feel comparable with such as Holland.
This fascinating survey published in the BMJ shows that 42% of nurses in England felt burnt out compared with 78% of nurses in Greece, 41% in Ireland and 40% in Poland. However only 10% of nurses in Holland and 15% in Switzerland felt burnt out.
Burnt out but still offering good care. A closer look at the statistics reveals that despite reporting high levels of burnout, nurses in England report lower levels than some other countries of wards that have ‘poor or fair quality of care’. For example 19% of nurses in England reported the ward they are working on to have ‘poor or fair quality of care’ compared with 35% in Holland, 27% in Sweden, 35% in Germany and 28% in Belgium.
Nurses were also asked if they would give their ward a poor or failing safety grade. The results from the nurses in England were comparable with the majority of other European countries at 7% compared with Greece at 17% and Poland at 18%.
So burnt out but still soldiering on. But for how long? The survey shows 39% of nurses in England are dissatisfied with their job and 44% intending to leave their job in the next year. Let’s hope that a good proportion of the 44% are planning to find another job in the NHS otherwise there is a phenomenal crisis brewing.
This survey of 2,900 nurses at 46 hospitals took place in 2009-10 before the details and extent of the government health reforms became clear. So it seems likely that the level of stress and pressure of English nurses will move even closer to that of Greece as they face the uncertainty of life in today’s NHS.
'Is three years long enough to prepare our nurses for practice?'
When I was a student there were very few options for dressing a wound; eusol and paraffin, paraffin gauze, hydrogen peroxide or a dry dressing.
And guess what? Wounds rarely healed. The field of tissue viability has developed significantly over the last 20 years and now wound management requires considerable skills including detailed assessment and product selection.
This growth in nursing knowledge is not confined to tissue viability and the challenge is to squeeze more and more into the nurse curriculum so that newly registered staff will be able to hit the ground running.
Happy Newly Qualified Nurses’ Week!
You can read our FREE content on how to manage the transition from student to qualified nurse here
I remember being petrified on my first day as a staff nurse; a different uniform brings an expectation that you know what you are doing, have all the answers and are able to make decisions. You have passed your exams so you must be a competent practitioner.
But registration is just the beginning of the journey to becoming a nurse.
New staff nurses must be nurtured so they not only consolidate their practical skills but are able to live up to the guiding principles and ideals that brought them into the profession in the first place. Failure to give this support leads to frustration, disillusionment and ultimately loss of good nurses from the profession.
Perhaps nurse training just isn’t long enough. Extending it to four years to include a 12-month postgraduate preregistration experience would enable nurses to consolidate their theoretical and practical skills and begin the transition from novice to expert in a protected environment.
This would follow the pattern set by other professional groups. Pharmacy is now a five-year course with a one-year postgrad prereg course where pharmacy graduates gain essential practical experience.
Why can’t nursing replicate this model?
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