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New recruits lack basic skills says trust nursing director

The nursing director of one of the largest trusts in England has called into question education standards around basic nursing care.

Heart of England Foundation Trust director of nursing Mandie Sunderland particularly questioned the ability of newly qualified nurses to produce and understand care plans.

Speaking at the Nursing Times Delivering High Quality Nursing Care conference this month, she told delegates that new nurses were often not familiar with the “fundamental issues of care”.

“We’ve got a real problem as a profession. We’ve got a whole generation of nursing that doesn’t understand care planning,” she said during a presentation on assuring the quality of nursing care.

“We need to look at whether we’ve got the [pre-registration training] model wrong,” she added.

Ms Sunderland highlighted the example of newly qualifieds failing to understand the care pathway for pressure ulcers and, as a result, not calling for the tissue viability team when appropriate.

In order to address the problem, she called on delegates to respond to the NMC consultation on pre-registration training – the second phase of which will take place between January and April 2010 and will include new draft standards for nurse education.

Readers' comments (27)

  • As a second year nursing student, currently battling my way through Care Planning, I felt I had to respond to this. Our whole second year we will be learning different models of care planning, and although its tough work, I am getting my head around it and understanding the benefits. But it is not the students who are not implementing it! On every one of my placements I have never seen plans of care made in such depth and detail as we are taught because the nurses feel they have to rush through them to get everything else done. It makes it all the more confusing for students who are being taught one thing but being shown another. If more of the registered staff demonstrated thorough and accurate care plans it would lead the way for the students.

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  • i think its fair to say the students will nearly always blame their placement mentor

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  • I think that there are many factors that need to be considered in the area of care planning. In reality many settings ultilise core care plans that are adapted to suit individuals and while these are meant to make care planning easier for staff nurses, often staff do not complete these as they are considered to be of lesser importance than direct patient care. Of course for students core care plans are not ideal as an educational tool as they are more suited to staff who are well able to adapt them. Its not a matter of blame but I do agree that some staff do not complete care plans appropriately citing lack of time as the reason! Students and staff often confuse nursing process with care planning and are unable to distinguish what exactly they should be doing. When I was a student we had to hand write individual plans of care for selected individuals, based on assessment of needs, identification of problems, plan of care and evaluation of same. As we did these on every placement and had to consider the rationale for care given we soon became familiar with nursing care management of various patients. As a nurse educator who works in the clinical setting I continue to prompt students to think this way enabling them to become knowledgable doers who can effectively plan care based on the best available evidence/research. It's not about being hightech or overly educated its about being practical in your approach to caring and taking pride in knowing how and why you are doing it. Many experienced nurses do essentially plan care but may not have the best resources to document same. It is my experience that both staff and students need assistance in this area. We regularly hold education sessions that remind staff of the importance of care planning from a legal perspective as well as from a caring approach and we are now planning update sessions for staff in the area of care planning so that they feel supported in their practice. As a teaching hospital we have a responsibilty to our students but overall we have a responsibility to our patients to effectively plan care based on their needs that will ensure that they receive the appropriate care required. Managers need to ensure that if staff require support or education then this must be facilitated.

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  • When will managers understand that care planning is a time consuming part of a nurses role! When will nurses be given protected time for writing and updating them? When will somebody realise that delivering health care is expensive and put more resources into front line care to enable nurses to carry out the ever increasing responsibilites they have.

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  • It is fair to say that students will blame their mentors, but if the student saw their mentor doing something grossly wrong they would be the first ones to pipe up and complain. Students should stop blaming other people and take some responsibility for their own learning. If they see other people not doing things correctly then they should be motivated to do it better themselves.
    To the second year student who said that they are taught one thing from one person and then another from another person, 3 words which you seem to have forgotten - EVIDENCE BASED PRACTICE. You may be taught many ways of doing something but ultimately you must make your own mind up on how you will do it based on the latest and best evidence.

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  • I am a third year student and find it quite sad that people feel the need to put the blame on students. Throughout my training we have had to develop care plans for patients, granted we may not have to hand write then as they are printed. But we still have to go through the nursing process (of which i believe care planning is a key element). I feel quite well prepared for the transition to the role of a staff nurse.

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  • I feel that it is hard to pipe up and speak out if we see out mentors not acting appropriately, some nurses thinks it's a waste of time us being in their work place and I myself have experienced this.
    I think that everyone should stop blaming each other and take responsibility themselves. There is a lot of articles blaming students for things!

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  • rovergirl6@hotmail.com

    Hello may i say as a retired nurse who was trained in 1972. i know thirty years ago, the points i want to make are .

    1)students are no longer trained to be nurses they are educated, this is a very different kettle of fish. this has come about since they have been sent to university for their education, I myself think this was a covert way of passing the financial aspect of nurse training away from the NHS. Cost cutting as a person who goes to university is not usually paid. because the nurses who go for education are actually working a bursary was applied to them

    we had our training on the wards and in the
    school of nursing attached to the hospital.

    2) trainee nurses spent more time on the
    wards,

    3) they were a member of the team from day one.and they had the ability to learn basic skills from that day.

    4) I can not remember the word accountability used very much in those days. all nurses and trainee nurses were accountable for their own actions.


    5) all nurses were paid a living wage.

    6) Basic care was was taught by observation and practice ,usually by staff on the ward who were only too happy to have them there.

    lets go back to nurse training ,I think the problem may have arisen because the university nurses are sent on the wards to observe,they are supposed to be supernumerary,This in itself causes problems, because the ward staff resent them, another problem is that computers are taking the nurses away from the wards
    /a word about care plans. the method of care planning is very good ,
    Twelve activities of living Roper ,Logan & Tierney.
    Here all the necessary wants and needs are taken care of, this planning is time consuming and this also takes away the time for the nurses to be at the bedside. one problem i think is that the university nurses are so busy doing assignments,that they do not have the time on duty to learn basic care.











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  • May i remind everyone that there is 50% of time in university and 50% of time on placement. Any failure must equally be shared.

    This is a prime example of the practice-theory gap. Student nurses are taught the up to date, evidence based, patient centred, holistic way of doing things in university, but when they get out onto the wards things are a little bit different.

    As a qualified nurse on a ward the aim isn't to provide excellent care for all patients to ensure that they receive optimum treatment, but it's to get through that 1 shift where you haven't enough staff, there are insufficient resources, and there are too many demands made on your time.

    As a student your aim isn't to develop your skills in a supportive environment, learning from the best and challenging bad practice at every turn, your aim is to get through that placement, and to do that you are at the mercy of your mentor, so you fit in, you do as you are told, and only if the risk of being in coroners court is greater than than the pain that is any form of university/hospital appeals/disciplinary procedure do you say anything.


    Student nurses need to be given the time that they deserve by all members of staff, and should be valued for what they bring to the team - a fresh set of eyes every couple of months in your working area, often with experience of other clinical areas, and prior life experience, and an ability to ask questions we often loose upon qualifying.



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  • Martin Gray

    Nurses are supposed to be intelligent people, so why is there is never-ending debate going on?
    I don't like the current method of nurse training, notr the constant argument about it being a degree-only profession. There are more than enough opportunities for nurses to attain the level they wish to; indeed, for some, I believe the higher academic qualification they can achieve is their main goal rather than caring. I read in one thread of a nurse that left the profession after 18 months then returned and has since done her MSC and is looking forward to doing a PhD - to what end except personal achievement? Being a PhD does not make you a better nurse; indeed it is more likely such 'nurses' will progress into teaching and academia rather than caring.

    As for care plans; are they often just needlessly complicated? And why are there so many? there are admission care plans, 3 day, 5 day, 7 day etc.... what purpose do they serve? Surely a care plan, irregardless of admission length, must concentrate on the same things and specialised in those areas relevant to the individual patients' condition. I recall having to write essay style answers in my finals; in these we had to show, not just the specific care and therapy required for the condition, but also the basic nursing required....diet, environment, personal hygiene, spiritual needs, etc...

    Nurses DON'T need a degree but can achieve the highest level they wish once qualified, so WHY is it so important when our profession has lost its' standing, not through the level of entry education, but on the way in which nurses provide care at the most basic levels to stipulate this entry level?

    My one wish is that students were given a decent wage, money being freed by reducing the number of managers. Pay a person a decent living wage and they will be more inspired to give their all rather than relying on the kudos( now lost I fear) of being privileged to become a nurse being used as the carrot on the end of the stick.

    Qualified nurses need to be more tolerant and supportive; students need to be willing to get stuck in and do the practical work and stop 'observing' on the side lines - which must be boring and quite frustrating for them. You cannot say there are not enough staff when you have students standing about observing!

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  • No one seems to talk about the art of nursing anymore , a skill learnt in the practice setting and school of nursing. I did a basic 'apprentice style training' and consolidated this with a couple of years as a staff nurse , again a role involving socialisation, appreciation and understaning of professional discipline required to be an effective nurse. This includes consideration and respect for all members of the ward staff not just academic competition or simply learning a technique because that is part of the learning objectives or a box ticking culture ( which seems to occur with some nurses). I worry that some nurse are signed off on the practice side who are patently not
    functioning at an acceptable standard and actually are a risk. Some do not appear to have absorbed any of the professional discipline that would have been a basic requirement in the former training, compassion, and anticipating patients needs . The training today demonstrates lots of assertiveness ( which is OK at the right time, other wise just sounds, rude! )but no listening skills. I have since gone on to graduate with a degree in healthcare but feel that it gave a greater depth and understaning to my basic training, and certainly widened horizons . I still feel that so much can be learnt about a patients' conditiion(unobtrusively of course) from a basic bed bath done to a professional standard, ie checking mucosa of eyes for possible anaemia , detecting depression from the patient's conversation, checking wound drains, blood loss or signs of infection on dressings, pain etc . I feel that students are being taught to run before they can walk without that all important practical understanding and professional approach/knowledge of nursing care. Care plans work when there is apractical understanding of the information required in them!

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  • one comment i feel is needed here.

    care plans are legal documents and if the nurse writes the patients needs in a care plan they have to be carried out.

    Also their wants are regarded as secondary

    So long as their needs are met.

    i may be wrong on this as i left nursing in

    2008,things may have changed.

    .

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  • Ditto every word fom Martin Gray.

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  • As a student now coming up to my final year of training, I am dissapointed at the continual blame bounced back and forth.

    It is true there are many students who stand on the sidelines preferring to use their status as supernummery to avoid hard graft however there are also a vast amount of mentors that use students as HCA's, and do not actually take the time to teach the student anything, whilst basic care is fundermental and I personally love the time I spend doing so, a student can not gain the competance to be a staff nurse if they spend most of their time performing basic care and not encountering the other roles that will be expected of them, added to this there are HCA's who seem to dissapear when bells ring or observations need to be done leaving the student to perform these tasks alone, as well as those that stand around talking whilst a student makes a bay of beds, all of these issues need addressing if we are to improve.

    With regard to care planning, my university has done an excellent job in teaching these skillls and I was able to implement them during a recent placement, managing 6 patients single handed.

    Students need to be responsable for their own guided learning, and not expect to be taught everything but please mentors do give us the chance to do things too!

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  • This is hardly news is it, it's been going on for years and will only get worse. Take training away from the universities and give it back to hospitals and schools of nursing

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  • So Mandie Sunderland doesn’t think newly qualified nurses can produce or understand care plans? The obvious question is exactly how would Mandie know? Maybe she is one of those Dir of Nursing who would have us believe she visits the wards every fortnight?

    I wonder if Mandie considered how badly her comments reflect on the nurses she leads at the Heart of England FT before getting all animated on a conference stage? As one respondent has already pointed out nurse education is split 50:50 theory and practice, so if the newly qualified haven’t got the requisit skills it’s as much down to the quality of clincal practice and supervision that students are exposed to as it is about what’s going on in universities. Furthermore most nurses aren’t stupid, if they have problems understanding the care planning process it’s probably because it’s unnecessarily complex and fragmented. I wonder if Mandie knows how many different assessment tools her staff nurses are expected to use? Instead of simply blaming the educational model, maybe she should reflect on what she and her corporate colleagues have done to make the work of those at the sharp end a little easier.

    If Mandie is really worried about the fitness for purpose of new RNs (rather than grabing a headline in the NT) I’m sure she’ll have taken her concerns up with the education commissioner at the SHA as well as the relevant university Dean and the Teaching and Learning Committee, a seat on which either she or her nominee would as a key stakeholder have by right.

    Finally, it would also have been nice if NT had done a little background on this story rather than simply lighting the blue touch paper and walking off…

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  • As a recently qualified staff nurse I feel it appropriate to comment on this issue. I was taught the roper, logan and tierney model of nursing at university, howeve during academic sessions we were never taught to accurately plan care. Many students have a tendancy to blame mentors for their lack of knowledge and skills, I know I have done this myself however I was justified in my blame as it was not only my mentor byt all staff in the clinical area and this was not rel;ated to my ability to complete care plans cause my written documentation was indeed the only thing those staff felt I was adequate at carrying out. However from my first year I learned to accuratley plan care on an individual patient basis.
    On every single one of my placements I accurately planned care with or without the assistance of my mentor. However even as a student there were occassions where there just wasn't time to update care plans because seeing to the critically ill pateints was more important and if felp like a pointless waste of paper as no other members of staff appeared to fill in care plans at all and if they did it was done incorrectly or the didn't bother to discontinue them when the patient no longer required that particular intervention. But at the end of the day care plans are legal documents and must be filled in order to provide basic patient care and not be seen as a neglectful nurse!

    I agree that nurses should not have to be educated to degree level because if you look at the NHS as it stands right now, many of the best nurses do not and those who do don't neccessarily participate in direct patient care which is the reason the majority of people pursue a career in nursing in the first place!

    I have worked alongside excellent students and qualified nurses of all levels who not only provide first rate direct patient care but are also brilliant at the documentation. However I have also worked with students and qualified nurses that do not do any hands on patient care and do not know how to do do basic tasks like write down observations from a monitor or admit a patient, or even to draw the curtains if a patient is upset! And none of this is the mentors fault or the universities fault, it is simply because the student doesn't apply themselves the way they should or participate in the care they are required to, to meet their competencies.

    In my opinon nursing should return to apprentice style training in the hospital wards and those nurses who wish to pursue nurse management or nurse educator careers can go and complete the relevant academic course to fufil their ambitions. I also thing that having recently ceased being a student that student should take responsibility for their own learning and not blame their lack of knowledge or skills on everyone other than themselves.

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  • As a recently qualified staff nurse I feel it is appropriate to comment on this issue. I was taught the roper, logan and tierney model of nursing at university, however during academic sessions we were never taught to accurately plan care. Many students have a tendancy to blame mentors for their lack of knowledge and skills, I know I have done this myself however I was justified in my blame as it was not only my mentor but all staff in the clinical area and this was not related to my ability to complete care plans as my written documentation was indeed the only thing those staff felt I was adequate at carrying out and I take responsibility for my lack of enthusiasm in that particular placement due to my lack of skills in certain area which was my fault and no one elses. However from my first year I learned to accuratley plan care on an individual patient basis.
    On every single one of my placements I accurately planned care with or without the assistance of my mentor. However even as a student there were occassions where there just wasn't time to update care plans because seeing to the critically ill pateints was more important and it felt like a pointless waste of paper as no other members of staff appeared to fill in care plans at all and if they did it was done incorrectly or they didn't bother to discontinue them when the patient no longer required that particular intervention. But at the end of the day care plans are legal documents and must be filled in order to provide basic patient care and not be seen as a neglectful nurse!

    I agree that nurses should not have to be educated to degree level because if you look at the NHS as it stands right now, many of the best nurses do not possess degrees in nursing or healthcare and those who do don't neccessarily participate in direct patient care which is the reason the majority of people pursue a career in nursing in the first place!

    I have worked alongside excellent students and qualified nurses of all levels who not only provide first rate direct patient care but are also fantastic at the documentation. However I have also worked with students and qualified nurses that do not do any hands on patient care and do not know how to do do basic tasks like write down observations from a monitor or admit a patient, or even to draw the curtains if a patient is upset! And none of this is the mentors fault or the universities fault, it is simply because the student doesn't apply themselves the way they should or participate in the care they are required to, to meet their competencies.

    In my opinon nursing should return to apprentice style training in the hospital wards and those nurses who wish to pursue nurse management or nurse educator careers can go and complete the relevant academic course to fufil their ambitions. I also think that having recently ceased being a student that students should take responsibility for their own learning and not blame their lack of knowledge or skills on anyone other than themselves.

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  • rovergirl6@hotmail.com

    surely basic care could be taught in the first academic year,And as the education continues through the three years , each and every year more and more of the education to fulfil the role of a qualified.accountable nurse can be taught. remember the qualified nurse on the ward is not only accountable for their own actions they are responsible for any and all actions of their subordinates.

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  • Malcolm Chalk BA, RN

    Looks like another case of an old school nurse having a go at the better academically trained nurses this country now produces - sour grapes perhaps?

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