Practice team blog
I recently had to attend an outpatient’s appointment at my local hospital. As I went through the front door, the reception staff gave me a cheery wave as I headed down the corridor towards the clinic. Two people that I passed in the corridor, who were in uniform of different kinds, said good morning to me and, at the entrance to outpatients, I was greeted enthusiastically by someone directing the traffic of patients.
Sometimes at outpatient reception the presentation of an appointment card has been carried out as a wordless exchange but not this time. I was again greeted with a good morning and directed to a bank of chairs. While sitting there a couple of hospital staff came through the area and said good morning to those of us in the waiting area.
Whenever I have been on holiday in France, I have wondered about the French custom of saying bonjour to everyone they met. Even someone entering a shop where others are standing queuing will say bonjour to all those already there. But actually I think the custom of greeting those that you meet acknowledges your common existence and binds us all together.
During my hospital visit I found the experience of multiple greetings and general friendliness a supportive and positive experience. While the cynic in me might think that they were only saying good morning because they had been told to, it was in fact part of their job, and a part that they did well and which made a difference to me as a patient.
“You have to understand GP practices are businesses, and have to operate in that way as making money is one of their priorities.”
This may sound obvious, but it wasn’t until Carol Hedger, a tissue viability nurse specialist, showed me the effect this has on some practice nurses and their patients, that I realised the true impact of this statement.
GP practices receive funding for treating asthma among other conditions and for the number of flu jabs they administer, very little funding is allocated to wound care. Patients with chronic wounds are unlikely to be referred to a specialist clinic and tend to be managed in the community.
Frustrating for a nurse like Carol who is desperately trying to make people see that long-term wounds are both avoidable and treatable. Once you find out why a wound isn’t healing, the patient’s quality of life can be improved considerably.
Like most specialist nurses, Carol’s caseload is simply too large for her to offer individualised care herself. Her priority has to be on educating nurses and patients. Carol visits practices and works with practice nurses to identify the causes of chronic wounds and teach them to assess why wounds aren’t healing.
When a woman attended Carol’s clinic with painful cellulitis, she discovered that both the doctor who had originally seen the patient, and the nurse at the follow-up appointment, had not assessed for oedema – a high risk factor for cellulitis. Luckily for this patient Carol did assess and was able to plan care appropriately.
Similar patients attend some practices week after week with little or no change. They are offered alternative dressings but the underlying problem is not assessed.
As Carol puts it: “It isn’t the dressing that heals the wound, it’s the body. If a wound isn’t healing you need to be asking why and treating the problem, not the symptom.”
Sound advice, but is this possible in a 10 minute appointment? And with funding diverted elsewhere, do practice nurses receive enough training to confidently assess the underlying conditions of chronic wounds?
We’re all accustomed to hearing how memory problems are common – or even inevitable – in older people. And if you’re anything like me, each time you enter a room and forget what you came for you’ll think it’s a “senior moment”, a sign of things to come.
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But perhaps this stereotype is a self-fulfilling prophesy. A study undertaken by researchers at the University of Southern California suggests that negative stereotypes about ageing can actually impair memory. The study found that a group of older people asked to perform memory tests after reading fictitious articles about age-related memory problems did less well than a group given articles on preservation of and improvement in memory with age.
The researchers tested their results by giving participants a range of memory tests, with different positive or negative effects related to performance. Their results consistently showed that concern about being negatively stereotyped impaired memory.
It strikes me that our attitudes to older people may be harming them in more than memory alone. How often do we assume that an older person will find it difficult to perform a task and that it would be better to do it for them? Or do we tell ourselves it will be better for them when we really mean quicker for us?
And when we discuss the fact that the proportion of the population over retirement age is growing as the baby boom generation swells its ranks, it is usually in a negative context. How will we care for all these dependent older people? Who will fund all this care?
Of course old age brings a certain amount of decline in function, but perhaps if we took a more positive view of older people they would retain their physical and mental abilities for longer. Maybe then we wouldn’t be worrying quite as much about how health and social care services will cope with the “timebomb” of the ageing population, and instead looking at how older people can remain actively engaged in and contributing to society.
The sight of Mick Jagger jumping around on the Glastonbury stage just a few days short of his 70th birthday was a clear demonstration of the changing demography in the UK. The Stones’ drummer was even older at 72 but he, of course, was sitting down.
Tom Jones is another example of how people are staying younger longer. Aged 73, he looked in good health and at ease on the recent series of The Voice. So yes it’s clear that people do live longer and in better health than they did when Mick first hit the stage 50 years ago and when Tom Jones first sang the Green Green Grass of Home
The number of people living beyond 75 is going to significantly increase and will present a challenge to heathcare. Although it would be great if he could, I think unfortunately Mick is unlikely to be able to repeat his Glastonbury performance in 10 years’ time at the age of 80.
People are living longer but as they age they will be prone to more ill health and will put pressure on current services. We must not miss the chance to prepare for the complexity of care that this group will present to nurses.
Particularly beyond the age of 80, people tend to have raft of interlocking comorbid conditions. Managing and supporting their care often means solving a crossword puzzle of symptoms and issues. This challenge requires skilled staff who have experience and training in older person’s care.
Those responsible for training nurses and other health professionals must guarantee that those caring for our aging population, including our rock stars, are properly prepared and have the range of skills that they need.
It’s another day and there is a new initiative for you to implement. In a bid to improve patient safety and make lines of accountability clear, the health secretary Jeremy Hunt has come up with the idea of putting the name of an accountable nurse above every patient’s bed.
I know – it seems like we have been here before. Anyone around in the early 1990s will remember the named nurse and may be quick to dismiss this idea. And there are certainly lessons to be learnt before we rush into a repeat.
The named nurse initiative of 1990s had its origins in a grassroots movement that aimed to develop the philosophy of primary nursing in the UK. This movement championed the nurse-patient relationship and the vital role that continuity of care played in ensuring patient-centred care. This involved a fundamental change in the way care was organised and delivered.
The success of this approach in a small number of enthusiastic wards and units led to a government policy to implement a blanket named nurse system across the NHS irrespective of whether they had adopted a primary nursing approach to care.
Hours were spent discussing who could be a named nurse - was it just for a shift or length of stay; what happened when staff were on days off etc etc etc.
The failure of this policy lay in rushed implementation, managers and nurses failing to understand why they should do it and inappropriate staffing levels. Fundamentally there was a failure to appreciate that for the nurse-patient relationship to be successful there needed to be a fundamental shift in the way nurses thought about, organised and approached care.
The net result was a cosmetic implementation of the policy, with whiteboards and name badges, which fizzled out as people tired of the “not my patient” reply to every question.
I don’t think this is what Jeremy Hunt is trying to resurrect. But sadly I think it may suffer the same fate with a new generation of nurses.
What worries me is this idea is born out of a need to be seen to do something rather than any real understanding of the problems ward nurses face day to day. We have fundamental problems with staffing and skill mix on many wards and the prospect of major staff shortages in the next few years. There has been a systematic failure to invest in our ward sisters over many years and as the Francis report identified there is a crisis of clinical leadership in nursing.
So by all means put the names above the beds, but it will not make an already overstretched workforce work any differently or any harder. All it will do is make many nurses feel they are being “done to” yet again. Another change with another audit to ensure it is carried out.
So please Mr Hunt, invest in nurses first. Only then will you have a chance of meaningful change with a long-lasting impact on patient safety.
Last week I visited a ward that was actually well staffed; it had a proactive approach to staff education and an experienced and very effective ward sister. The ward was calm, tidy and every patient I spoke to knew their nurse. They didn’t need a name above the bed.
What more can I say?
Yesterday I went to see a play Inside out of Mind. Based on a dementia admissions ward it told the story of staff and patients. It captured the chaos, noise and unpredictability of the ward as well as the emotional and physical demands of caring for people with dementia.
We saw how staff formed close bonds with patients and cared deeply about them but were challenged by some of their behaviour which clearly upset and confused patients. I was upset by one scene where staff and patients sat together wearing witches hast for a ward Halloween party – well-intentioned, but please don’t do it to me if I end up on your ward!
It was evident in the performance that not only patients but staff become institutionalised. In response to a question “Where do you go for help?” one of the characters - a ward sister- says “We keep it all inside”.
But this play is not fictional, it is based on research conducted on dementia wards. Justine Schneider was commissioned by the UK National Institute for Health Research to carry out an overt participant observation study of health care assistants caring for people with dementia.
The researchers worked as supernumerary HCAs in three wards for people with dementia and behavioural problems.
Commissioned to inform policy and workforce planning, I expect the final report could, like countless others, have sat on a shelf gathering dust. Justine tried to organise feedback sessions for staff once the report was completed but the attendance was poor.
She wanted to find a different way to communicate what she had observed to others. So she approached a theatre company to write a play based on the transcripts. Her hope is that Inside Out of Mind “will help people to understand that dementia care is not easy, wherever it is provided, and that the people who do it well deserve our admiration and respect”.
I watched the play with an audience of HCAs from three trusts in Nottinghamshire who were visibly moved by the performance. The trusts had arranged for staff to see the play and attend workshops to discuss the issues that arise.
I am not claiming this one play could change the face of dementia care but as part of a strategy to educate staff across large organisations it appears to be a refreshing and exciting approach.
I am fascinated by the collaboration between researchers, NHS trusts and the arts working together as a way of helping staff to walk in the shoes of people with dementia. It has also helped outsiders like me walk in the shoes of healthcare assistants.
For more information about “Inside Out of Mind” visit www.lakesidearts.org.uk.
Since the government aimed its Francis report response firmly at nurses, with many of its promises focusing on “improving” nursing care, I have felt a sense of injustice that the wrong group is being targeted.
The assumption that nurses somehow lack compassion is completely unfounded. As someone recently tweeted to NT “No one goes in to nursing for the pension, we do it BECAUSE we’re compassionate.”
But the unfairness of it only really hit home when I received a phone call from my Mum at 11pm one evening last week.
She was on her third day on an acute surgical ward with advanced appendicitis.
Having not eaten for 38 hours due to her surgery being pushed back, and then pushed back some more, she was already distressed and disorientated. She had then been told that her surgery would not be going ahead that evening as planned and no one could tell her when it would be.
What’s more, she was being moved to another ward. She didn’t know why and she didn’t know where.
I later found out that the people making these decisions were on the ward at this time but instead of having the common courtesy to explain their rationale to patients face-to-face, it was left to the nursing staff who had just come on duty to deliver the bad news.
My Mum was angry, upset and in pain having refused her morphine because she wanted to be “with it” enough to find out what was going on. She’d barely slept and was clearly frightened about having surgery.
Throughout the entire phone call I could hear a call bell going off unanswered, eventually attended to by another patient.
And yet, through all this chaos, my Mum’s unrelenting praise for the nursing staff shone through.
Having never even heard of the 6Cs, and entirely unprompted, she used the word “compassionate” to describe her nurse, Vicky*.
I find it insulting and downright patronising that the suggestion is even being made that Vicky and her colleagues somehow lack compassion.
I met Vicky on my next visit and we discussed how her concerns for patient safety have increased as clearing beds has been prioritised. She told me the story we’ve heard time and time again about how her attempts to raise concerns have been ignored or dismissed with no changes being made.
The very fact that Vicky wishes to remain anonymous highlights that staff feel they aren’t safe to raise concerns. But for things to change, they need to not only be able to speak out, but to shout out when they are left in situations where they simply cannot do their jobs safely.
Vicky is the perfect example of why our Speak out Safely campaign is so important. Following Robert Francis’s recommendation, we want to make it a legal requirement for management to act on your concerns if patients are being put at risk.
Let’s stop pointing the finger of blame and address the real problems here. Show your trust that you are behind us, behind nurses like Vicky and behind a safer, more transparent NHS. Sign the SOS petition.
In the NHS some patients are more equal than others.
That was a message I got from delegates at the Association for Continence Advice conference last week.
Because some commissioners think bowel and bladder care is important and others don’t.
We have discussed the outcome of rationing care on this website before. Remember the case of Elaine McDonald? Ms McDonald lost a supreme court appeal against the London Borough of Kensington and Chelsea’s decision to withdraw the night-time care that enabled her to use the toilet. Instead Ms McDonald was told to use incontinence pads – even though she has mobility problems rather than incontinence.
The indignity of passing urine into a pad when you know you could go to the toilet is unacceptable. Yet our continence services are under immense pressure and in some areas commissioners, looking to save money, may see continence as an easy target.
Why treat a problem when you can throw a pad at it – and, while you’re at, it ration the number of pads?
Those who have the money can top up their supplies, while everyone else has to make do. In a #NTtwitchat last week people talked about the human cost of rationing: drying pads so they can be used again or providing a pad that lasts 12 hours so less care is required for toileting.
It is nurses who inevitably have to deal with the consequences of offering different levels of service to their patients depending on who is commissioning care.
How do you explain to Mrs Smith at number 46 why she gets one service while Mr Green at number 72 – with a different GP – gets another?
How do we reconcile the compromise this inevitably entails? Is it just the new economic landscape of healthcare that we have to get used to?
The uncomfortable realities of competition care are beginning to bite. What is your experience?
The Telegraph’s website the other day carried the headline “Minister: NHS will collapse if elderly bed-blocking continues”.
The story itself was a reasonable discussion about the need for better integration of health and social care to ease pressure on hospitals and ease the crisis in A&E, but the headline implied older people were to blame for all problems in the NHS. It conjured up images of stubborn older people refusing to give up hospital beds they no longer need, selfishly forcing younger people to wait for urgently needed care.
My 85-year-old mum recently spent two weeks in hospital, and the nursing care she received was faultless – every one of the 6Cs shone through in all the nurses on her ward. Nevertheless, the experience was distressing and confusing and all she wanted was to go home. And that’s exactly how most hospital patients feel, whatever their age.
The casually insulting tone of The Telegraph’s headline reminded me what a shame it is that the government has not accepted Robert Francis QC’s recommendation to create a new older person’s nurse specialty. These nurses could have expert knowledge of the ageing process and age-related conditions, and an understanding of the particular needs that ageing brings.
Older people’s nurses could help non-specialist colleagues across multiple wards or teams, and take a lead in caring for patients with particularly complex needs. And like cancer nurse specialists, they could smooth their patients’ path through health and social care, chasing test results, co-ordinating discharge plans, and ensuring all relevant professionals, family members and carers are involved and informed as appropriate.
I hope that when it makes its more considered response to the Francis report later this year the government will announce that it will, after all, create an older people’s nurse qualification with registered status. These nurses could do much to improve the experiences of older patients, and may also help to reduce the pressure on hospitals by reducing inappropriate A&E attendance and speeding up discharge by coordinating all care providers. Maybe they could also teach lazy headline writers that older people aren’t to blame for NHS problems – in fact they have spent a lifetime paying for it.
This is Dementia Awareness week which is a good way to call attention to this common condition. But in reality every week needs to be dementia aware for nurses. And it’s not just for nurses working in care of the older persons and in nursing homes. All nurses will come into contact with patients with dementia – on surgical wards, in A&E, outpatients, GP surgeries and out in the community.
Simple strategies can really help to make communication easier. Take a look at an article we published recently which gives some useful tips. It sounds simple but it will make a difference. For example, avoid asking open-ended questions such as “What would you like to drink?” but ask instead “Would you like a drink of water?”
And think about the environment where you work. With the increasing number of people who have dementia, and will have it in the future, it is time to think about how you can make the space where you see patients more dementia-friendly.
Take a look at our excellent article written by June Andrews at the Dementia Services Development Centre at the University of Stirling. Even small adjustments can make a difference. For example, having doors in contrasting colours to the walls makes it easier for the person to navigate their way around.
We are having a twitchat at 1pm on Wednesday 22nd May. If you have strategies that you would like to share please join us for the chat. It is an important subject – this and every week.
Rapid tranquillisation on mental health wards is much-debated.
On the one hand, rapid tranquillisation is sometimes needed to maintain the safety of the ward, on the other hand it carries with it extreme risks to the patient, can be addictive and arguably should be the last resort when all other methods of de-escalation have failed.
Patients are often subscribed tranquillising and antipsychotic drugs PRN so they can approach staff if they feel they need additional medication. In my experience, this can work well with patients being afforded the opportunity to take responsibility of controlling their symptoms before escalating.
However, as a staff nurse what do you do if a patient asks for medication they do not appear to need?
As you can’t tell what’s happening in someone’s mind, should you take their word for it that they know what they need?
What if they have been sitting watching TV, appearing calm for the past hour, and strolled to the nursing station to request highly-addictive benzodiazepines?
Giving medication without clinical need is not in the patient’s best interest and may in fact be feeding an addiction.
But, what if saying “no” leads to aggressive behaviour, putting patients, staff, visitors and the hospital environment at risk?
I have witnessed patients requesting lorazepam without clinical need only to be, rightly, refused this by nursing staff. In order to ensure they got the medication they wanted, I’ve seen patients then damage hospital property, threaten staff and other patients and escalate to the point that staff have no choice but to medicate in order to maintain the safety of the ward.
This positive reinforcement of disruptive behaviour only leads to the same happening again.
Benzodiazepines are all too often given without consideration to the long-term consequences. The MDT must look at ways to balance the short-term benefits of using these drugs with the long-term affect they may have on the patient and the nature of their care.
What do you think? Do we give out too many benzodiazepines without considering the consequences of long-term addiction? Are we too quick to use rapid tranquillisation to de-escalate?
There is an old man who occasionally catches the same bus as me to the station. When he arrives at the bus stop there is an odour which in the confined space of the bus gets worse.
It took me a while to work out that the smell was from compression bandages on his legs which are usually heavily stained with exudate. Month after month the smell hasn’t improved and I would assume neither have his ulcers.
How does he feel when people instinctively move away from him, look the other way or fan themselves with a copy of the Metro?
I can’t make a judgement on his care or whether he is compliant but I do wonder whether his wound management is based on the best available evidence.
Management of leg ulcers, unlike other nursing activities, has a fairly robust evidence base. A well-managed venous ulcer can heal and we have a host of products for management of odour and exudate.
Sadly, the evidence has also highlighted the profound psychological effect ulceration has on people’s lives leading to social isolation, depression and anxiety.
So when I look at my fellow bus companions bandages I am left wondering about the research-practice gap.
Who is removing this gentleman bandages and assessing his symptoms?
Is anyone talking to him about how he is managing is hygiene and washing is clothes?
Has anyone talked to him about his shoes that don’t fit comfortably over the bandages?
Has anyone asked him how he feels?
The application of compression bandaging is a specialist skill and the Leg Ulcer Forum is clear that it should be undertaken by nurses with specialist training.
However not all patients have access to specialist services and the net results is on-going, expensive and ineffective care that has a negative impact on patients.
We all have a responsibility to use evidence based practice but practitioners need to have access to it. While practitioners should ensure they are up to date, researchers must ensure that their work is disseminated as widely as possible.
The problem is academic institutions usually measure the value of its researcher by their publications in academic journals with impact factors. This measure is not based on the impact on patient care but on the number of citations to the journal - those with higher impact factors are deemed to be more important than those with lower ones.
Perhaps it is time for researchers’ success to also be measured by their impact on patient care.
A friend recently tried to have a Doppler scan and tissue viability assessment in the community rather than in the hospital.
Sounded sensible – just around the corner.
But the saying is there is no such thing as a free lunch. And in this case it seemed there was no such thing as accessible care.
A trip to the hospital is only another 30 minutes on the bus and as it turns out this would have been time well spent.
Appointment number one failed as the staff member who could work the Doppler machine was not in until later. Appointment number two failed as the nurse using the Doppler machine could not get it to work properly – no back-up support available to assist. Appointment three failed because the wrong type of gel was available to get a reading.
Three weeks have now passed as the clinic only runs once a week. And the venous ulcer in question continues to exist but fortunately not to expand.
Running outpatient clinics and other services out in the community is good for the patient as it makes services more accessible and can be cost-effective.
The plan is that services for long-term conditions such as venous ulcers will be looked after by outreach and community services. But for this to work they must be properly resourced in terms of staff and equipment.
Community care is not supposed to be care on the cheap.
My friend did not feel the failure of each appointment was down to the willingness of the staff as each time the staff did their best to rectify the problems that occurred at each consultation. But that there was not the human and equipment resources to offer the service that deserved the commitment of the staff.
Throughout university we’d been taught that patients with this diagnosis can exhibit “challenging” behaviour, that they can divide teams and we should reflect on how we feel to avoid burnout.
Although we spent a great deal of time analysing how best to nurse patients with a personality disorder (PD), this was approached in a clinical manner. We barely covered the reasons why someone might choose to behave in these ways and want to spend their time in hospital.
So, what is it about this diagnosis that worries nurses before they’ve even met the patient?
Although those with PD can often put a strain on nurse time, I don’t believe reluctance to engage is the result of laziness.
Nurses join the profession wanting to help people. But trying to care for someone who appears to be thwarting attempts to be helped can leave health professionals feeling hopeless. It can be difficult to empathise with someone whose behaviour doesn’t always appear to fit with what they are saying. And even harder to put yourself in someone’s shoes when they are doing everything they can to avoid discharge, a situation that can often come up when nursing this patient group.
Let’s face it, mental health wards are a far cry from the Hilton so why do they want to stay?
It can be easy to forget thatBPD is an illness in itself and the challenging behaviour that can come with it is a symptom, not a personal attack. Understanding this behaviour makes it easier to get a grip on what is actually happening.
In my experience, this is where compassion can often fall down.
And, in these situations, maintaining unconditional positive regard can be difficult.
I agree with the Willis Commission that nurse education is of a high standard, but I feel that training is focused solely on helping and supporting people who want to get better. Little time is spent exploring the reasons why someone might rely heavily on services, often without any apparent reason.
Learning why someone may want to stay in hospital and go to extremes to resist discharge may help nurses, particularly those newly qualified, to remain compassionate when faced with challenging behaviour.
For this reason, it is essential that education on personality disorders centres on the reasons behind the presentation, rather than simply how to manage challenging behaviour.
After all, not everyone can learn compassion, but everyone can learn understanding.
Last week the ABPI released figures suggesting that doctors, nurses and other health professionals in the UK received £40m last year from pharmaceutical companies. The money pays for medical education events, training and development, and fees for services such as speaking engagements and participation in advisory boards.
I know many nurses, particularly those with specialist roles, benefit from the educational events and sponsorship offer by drug and appliance companies. But should professionals, who make objective decisions about purchasing products and drugs, rely on this financial support. Is it naïve to think there is no undue influence?
We all like to assume we would not be open to influence of the drugs industry but we have to question why spends such large amounts of money on us – after all their job is to ultimately to generate sales.
I have attended sponsored educational events and seen the benefits that could be gained from amassing potential customers in one place at the same time. If you have a new product to sell this is the ideal way to market it. Yet it is clear these events also provide valuable information and a chance from nurses to network and share experiences.
Many nurses are struggling to find funding for education and training and there is a growing dependence on industry financial support. Nurses who receive such support need to be clear about their relationship with industry, and this must be open and transparent. This is vital to ensure that we continue to serve the needs of the patient not the company who funds training.
But an additional concern is how we meet the training needs of nurses whose jobs do not fall into the target groups for drug industry investment. Post Francis there is clear evidence that all nurses need time out to reflect on care; to have supervision and regular updating. Who is looking out for all their training and networking needs?
Over the years I have seen the nursing profession deal with some enormous challenges, including seismic changes in nurse education, the eradication of an entire level of the profession and countless media storms – both justified and not.
For the most part, when the chips are down, nurses roll up their sleeves and get to work. Their morale may suffer, stress levels may rise and they may have a moan among themselves, but they generally handle whatever is thrown at them without kicking up too much of a fuss – at least not publicly.
However, the mood of the profession seems different as it absorbs the implications of Patients First and Foremost, the government response to the Francis report. I’ve seen far more openly expressed anger – from nurses at every level of the profession. And little wonder.
No other profession has faced the implication that it has been accepting the wrong people, with aspiring nurses facing a year’s work on the lowest salary rung as HCAs before three years of study. And exactly who did the government consult about this proposal? The entire nursing community appeared to be in the dark until the response was published.
Nursing competes to attract the brightest and the best – it wants people who have other options rather than those with nowhere else to go. While income is unlikely to be the primary motivator for most, the prospect of an additional year of financial hardship is likely to deter many excellent candidates from a nursing career. For people contemplating a career change or a return to work after having a family, that extra year could be simply unaffordable. And don’t get me started on how this flood of one-year-only HCAs will affect the wider nursing and HCA workforce – it’s too horrific.
I believe the profession has been insulted and shouldn’t simply accept its lot with weary resignation. Can you imagine doctors taking this on the chin? I can’t. So go on - get angry. Let the government know what you think of this insulting proposal.
The Francis report was clear that nursing was not working and made a series of recommendations broadly welcomed by the profession. Although it was damming about some nurses and the care they did not give it gave hope for the future. But this response to the detail and consideration in the Francis report feels a bit too much of a sideways swerve, a dodge even.
The Mid staff inquiry was permeated with stories of patients and relatives who felt invisible to the nurses who were supposed to be caring for them. Unfortunately it feels that the government response may have stripped out some of the elements that would have made the difference to day to day work on the wards. It does not mean that they will not happen but being left out today does not strengthen their cause.
For example the proposal of the key nurse that meant that an individual nurse would feel responsible for a patient’s care, the emphasis on how important it is for nurses to be present and active in ward rounds. Getting the ward sister out of the office and supervising staff and speaking to patients and relatives is mentioned but not supported in resource terms.
All these sensible and practical measures have instead been overshadowed by a scheme, not even proposed by Mr Francis, to have student nurses do a full year of pre-training training. A scheme so full of problems – how it is supervised, supported and resourced. What is the point/cost of continually training HCAs who will then disappear off?
The impact of the pre-training year will not be felt by the patients for many years, if at all. There are however some measures in the Francis report that will make a difference now. Let’s be sure that we don’t lose some of the good stuff and don’t let it be overshadowed by the crowd pleasing candy.
Years ago I worked with a nurse manager who was happy to tell her staff that their standards were too high. She rarely ventured onto the wards where standards of care were a problem. Wearing a suit and managing with extremely long arms from an office several floors away from her wards meant she rarely saw a patient let alone what was happening behind the curtains.
Can you manage nurses if you don’t actually nurse?
The recommendations of the Francis report suggest nurse managers need to be more clinically involved. But we have created a system that undermines the value of clinical care. Career progression with higher status and salaries takes our most able nurses away from the bedside. This creates barriers between clinical nurses and nurses who don’t nurse. Nurses commenting on this website appear to have little regard for their managers because in their eyes they lack clinical credibility.
Perhaps, on this issue, we can learn something from medicine. Doctors place great value on clinical skill and expertise. Doctors in management positions practise medicine and also go to meetings. Medical directors look after patients. So when they talk about medical issues they are informed by first-hand experience, who can argue with that?
Sadly, walking wards and spending time with staff once a month or even once a week does not equate with being a clinical expert.
It would be great if nurse managers carried a clinical caseload but how would it work in practice? I am interested to hear your views.
We often receive calls from people with random queries or requests that we simply can’t help with.
I’ve had students asking me to send everything we’ve ever published on the subject of an assignment, authors asking for copies of articles they wrote over 20 years ago but can’t remember exactly when, and patients asking me for a second opinion on advice from their GP.
However, something told me this call was different – the caller was obviously struggling to control severe distress and I knew I had to at least listen, whether or not I could offer any practical help.
She was a nurse who had raised concerns about patient care and been rewarded with a horrific experience of bullying that had left her traumatised and unable to work.
The only practical help I could offer was to refer her to Patients First, the organisation set up to support NHS whistleblowers.
However, the call brought home to me the reality of just how badly some health professionals are treated when they try to take issue with colleagues’ poor practice, in a way that simply reading about similar stories couldn’t.
We decided to wait until the Francis report was published as we knew this would bring the issue into the spotlight. It was a long wait, but we hope it was worth it.
We have since had people question elements of the campaign, and in particular, whether we are aiming only to improve protection for people who take their concerns outside their employing organisation.
So, to be clear, we want to make it safe for health professionals to speak up about patient care and safety issues within their organisations, and to have their concerns taken seriously so that they don’t need to take them outside.
We realise that after serious harm or injury is too late, so we want to achieve a situation where people will feel able to speak up when their concerns are at a level that can be easily addressed and nipped in the bud.
After all, the dreadful examples we’ve all read about at Mid Staffs, Winterbourne View and elsewhere didn’t appear out of nowhere.
At some point, people got away with minor incidents that made them feel they had a licence to get away with worse.
So our petition calls for implementation of Mr Francis’ legal duty of candour for healthcare providers and professionals, obliging them to speak out when patients are harmed.
His other recommendation that it become a criminal offence to prevent someone speaking out was added to ensure health professionals have legal protection against the sort of bullying my caller and many others have experienced.
And we’re also adding to his recommendations that disciplinary action should not be taken when people speak out, unless a criminal offence has taken place or it would be unsafe for someone to remain in practice.
We believe this will enable organisations and individuals to learn from incidents, and for those responsible for poor practice to realise they can’t get away with it (and hopefully to receive training or support to improve before it becomes a disciplinary issue).
The other two elements of the campaign focus respectively on concerns raised internally and externally. Persuading trusts to make explicit that staff will be supported when raising genuine patient concerns should help to ensure their concerns can be addressed internally.
However, if they do need to take their concerns outside, we believe a full review of the Public Interest Disclosure Act is needed to ensure they are protected and that any as yet unidentified loopholes are closed to ensure others don’t have the experience of Jenny Feccit and her colleagues, who did not receive the protection from bullying they had hoped for.
We’re in it for the long haul on the campaign – asking governments to enact new laws or amend existing ones rarely results in a quick response.
But if you all sign our petition – and persuade colleagues, friends and family to do so too, we’ll get there.
And that’s vital – for both patients and professionals.
Six months ago I received my second favourite text to date. A picture of an eight week ultrasound and the words “You’re going to be an aunty!”
My sister-in-law’s pregnancy was ridiculously smooth. No morning sickness, no drama, in fact the most exciting things got was when she posted on Facebook about eating pork pies – was she finally experiencing a pregnancy craving? No, she’d just found a really good pork-pie shop.
Things went so smoothly in fact that when, four weeks before her due date, the baby hadn’t turned we all assumed she was just taking her time and all would be fine. But she didn’t turn and remained breech.
As the realisation that she would most likely be having a caesarean hit home it occurred to me that despite my three years of nurse training, I had no idea what was going on.
“They’re going to try and turn the baby” They can turn the baby from the outside? “The fluid levels are the low-end of normal” Babies have fluid levels? “She’s going to be conscious throughout the c-section” She’s going to see the operation?
Whenever I voiced my lack of understanding or grilled any mothers I know about their interpretation of what was going on, I was met with the same quizzical look and the comment “But you’re a nurse – surely you know about all this!” But the truth is that I didn’t know. My training is in mental health and even my general placements didn’t go anywhere near perinatal care. I may be able to recite section-rights in my sleep but advice on anything remotely physical? No chance.
Although the feeling of helplessness is so much more acute when it’s your own family, it occurred to me that I often felt like this working on mental health wards whenever someone came in who had a physical problem.
The word ‘nurse’ covers so many different areas that at times I’m almost hesitant to use it to describe myself. The roles of mental health nurses and general nurses are so different I sometimes wonder if they should even carry the same title. Particularly as public perception of what a nurse is tends to be limited to general nurses, despite nurses being present in all areas of healthcare.
Is this something only mental health nurses experience or do nurses from all specialties have those moments when they feel their knowledge doesn’t quite live up to their Staff Nurse title?
Incidentally, I now have a new favourite text: “Isobel Eve Entwistle born at 11.59 today, all is well with everyone”.