Jane Hapworth was a model nursing student. Her manner with patients was excellent, her career looked promising. But her command of the written word was poor.
Dyspraxia – a condition associated with problems of perception, language and thought – meant Ms Hapworth struggled with note-taking. The problem came to a head when she showed a senior nurse her notes following a ward round. They were illegible and also dangerously inaccurate.
‘A lady on the wards was waiting for a sigmoidoscopy. The student had written that she was having a cystoscopy. Fortunately I knew the patient so was able to spot the mistake,’ recalls the senior nurse who asked not to be named.
There are no statistics to show the scale of the problem – the NMC does not specifically record incidents of poor literacy and numeracy. But the National Audit Office estimates that there are 26 million adults in the UK who lack the maths or English skills expected of school-leavers. And in 2003, a Skills for Life survey, commissioned by the Department for Education and Skills, suggested that in organisations employing over 1,000 people, poor numeracy and literacy skills cost as much as £500,000 per year in lowered productivity.
Given that a trust’s workforce is well in excess of this number, the healthcare sector must be paying the price too. As well as being embarrassing and stressful for those concerned, these problems can impact
on colleagues’ time. More importantly, not being able to write notes or calculate drug dosages accurately has safety implications.
‘Good literacy and numeracy is essential for safe patient care. People have to be competent in this day and age. The consequence is a risk to public protection,’ says Garth Long, professional adviser for education at the NMC.
Anecdotal evidence suggests literacy and numeracy difficulties pose a significant problem in nursing.
Gary Wright, a charge nurse on a general medical ward at St Richard’s Hospital, Chichester, has come across problems. ‘One experienced staff member whose literacy is a problem has handwriting which borders on being dangerous,’ he says.
Over the years, Julie-Anne Hughes, a district nursing sister and team leader at South Staffordshire PCT, has also encountered difficulties. She says some nurses try to hide or avoid their problems.
‘They don’t want others to think they’re stupid. They might be wary, for example, of asking for help when calculating drug dosages,’ she explains.
She has also spotted staff ‘who get their numbers back to front’ or who have dyslexia – a learning difficulty that affects reading and spelling. Often, such word-blindness will have gone unnoticed, she says, particularly if they were educated during the 1970s and 1980s, when little was known about dyslexia.
Now, in theory at least, the academic standards for aspiring nurses are far higher and more rigorous than 30 years ago.
The NMC circular, Evidence of literacy and numeracy required for entry to pre-registration nursing and midwifery programmes, sets out the required levels for entry to the NMC register.
Approved educational institutions are expected to ensure that applicants for pre-registration education have provided, at the minimum, evidence of literacy and numeracy sufficient to undertake nursing education and practice at diploma of higher education level. For numeracy this includes, for example, being able to accurately manipulate numbers as applied to volume, weight and length. For literacy, it includes an ability to read and comprehend, and to communicate clearly and effectively.
But despite these requirements, some believe poor numeracy and literacy has been a growing problem.
‘For a period, numeracy and literacy in nursing was getting worse,’ says Guy Young, director of nursing at London’s Homerton University Hospital NHS Foundation Trust.
‘We have been seeing more drug errors than we used to, quality of record-keeping has been poor and there have been spelling and grammar issues which make it difficult to glean the information you need.’
He says one of the reasons for this might be that some universities have allowed students with inadequate skills to attend courses ‘to get the numbers up’, to help address the nursing shortage. He does add, however, that the quality of graduates in the last year has been better.
By the time a student has qualified, the NMC expects them to demonstrate the literacy, numeracy and computer skills needed to record, enter, store, retrieve and organise data essential for care delivery. But there is no specific testing of literacy and numeracy by the regulator.
As for HCAs and other support staff, there is currently no body responsible for their regulation, and therefore no organisation responsible for setting standards of literacy and numeracy.
Responsibility for the auditing and monitoring of records of all nurses and support staff is carried out on a local basis, so at a grassroots level employers are responsible for testing the literacy and numeracy skills of staff. This approach, the robustness of which will vary from one area to another, may explain why the skills deficits of nurses continue to slip through the net.
In an effort to strengthen literacy and numeracy, the NMC has produced Essential Skills Clusters (ESCs) guidelines for pre-registration nursing programmes, which set out the skills ‘nurses most need and must be met’. ESCs will be formally introduced from September and will include more explicit testing of literacy and numeracy, which will be integrated with other skills.
One organisation dedicated to developing solutions to problems related to numeracy and literacy is Skills for Health. At 10 pilot trusts across England, the organisation has been helping those responsible for staff development to promote these skills. ‘We are working to raise awareness about the importance of such skills and are trying to demonstrate the impact they have on quality care,’ says Rosemarie Simpson, its divisional manager for extending participation.
At some trusts, newly qualified nurses are given literacy and numeracy tests as a pre-condition of employment. At Homerton, for example, those who perform poorly in such tests but show a passion for nursing are given the opportunity to attend numeracy and literacy courses purchased through the Skills for Health Council.
Mr Young believes a joint approach to training is the way to tackle skills deficits.
He also believes in a ‘back to basics’ approach. ‘One nurse was having problems with drug calculations. So we supervised their drugs rounds as though they were newly qualified,’ he explains.
Ms Hughes advises that while it is important to be supportive of staff members with difficulties, it is also important not to ‘cover up’ problems. Managers can use the appraisal process to discuss literacy and numeracy issues and to encourage staff
to seek assistance and training.
‘A robust appraisal system will help these issues to come out,’ says Ms Hughes. ‘But managers have to discuss them in the right manner, rather than creating a culture of blame,’ he adds.
So in the absence of a uniform approach to tackling poor numeracy and literacy within the profession, nurses who lack skills are reliant on the support of their managers. Thanks to a senior nurse, for example, Jane Hapworth, the student with dyspraxia, is now back on target with her training.
‘We’ve come up with an action plan, met with her tutor, given her regular targets to meet and she’s also attending a basic English course. Without all this I wouldn’t have been happy for her to qualify. Now I know she will make a good nurse.’
Jane Hapworth is a pseudonym
How nurses can improve literacy and numeracy