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OPINION

'It’s easier to moonwalk than be a student nurse these days'

  • 9 Comments

My daughter has reached that stage in life when she asks really good questions.

Questions like “how do we measure good?”, “how do you know you are actually helping?” and “why can’t I have a corn snake?”

Her mother – a balanced and sanguine woman who, after 25-plus years in the health service has little time, particularly on a weekend, for our rambling – tends to reply to any debate around good and bad by doing her Michael Jackson impression. “Who’s bad?” she sings, breaking into a moonwalk and trying to distract us from our meandering. “Mum we’re trying to be serious – please stop dancing”, says our daughter, sometimes adding “at least until we are out of the supermarket”.

I am proud of my daughter for wondering, with some emotional investment, about good and bad. Not as proud as I am of my wife for being able to moonwalk near the frozen foods but proud nonetheless. I believe, rightly or wrongly, that the most important and insidious thing that is happening to our social sense during this “economic downturn” is that more important elements of social relations – things to do with values, morality, expectation and hope – are being redesigned. When that happens institutions such as the NHS become easier targets.

A few years ago I remember talking to people working on a Department of Health nurse recruitment drive. Their aim was to “sell” nursing as a profession that people could choose because of the career opportunities, working conditions (yeah, I know) and life choices. The recruitment angle sought to reframe the perception of nursing. No longer was it a “calling” or a “vocation”. It was being reshaped, being modernised – given a makeover. Of course, the problem with that approach was that, in trying to lift the perceived status of nursing to make it equal to other jobs, it downplayed the potential uniqueness that set it apart.

Still it broadened the answers that one received in interviewing prospective students. The putting-them-at-their-ease question: “So why would you like to nurse?” drew answers that ranged from a mumbled: “Dunno really” to “I am very ambitious. I plan to be a dame within a decade”.

I have noticed a change in the way that question is answered more recently. When done thoughtfully the answers tend to involve less about what it would enable someone to do and more about what it enables someone to be. Less about “I want to travel”, “I want to progress”, “I want to specialise” and more about “I want to be helpful and have a life that feels meaningful” or “I want to make a difference”.

I suppose at a time when so many young people are finding it hard to get work, nursing offers something that looks secure and reassuring and so one might expect the decision to come into nursing to be a logical and well-considered career choice. But the sense I am getting from many of the students is that it is more than a refuge from unemployment – it is also a search for meaning, a desire to help, even a stance against the disinvestment in “people” that the sort of economic cycle we are in now tends to attract.

I have a genuine, deep respect for modern students. They arrive at a difficult time, yet bring energy, commitment, hope and a desire to learn. That isn’t easy. In fact, perhaps it is as hard to be a student now as it has ever been. I don’t think it does any harm to notice that now and again.

  • Go to studentnursingtimes.net for a comprehensive package covering wellbeing, financial advice and study skills to support your student experience.

Mark Radcliffe is a senior lecturer and author of Gabriel’s Angel.

  • 9 Comments

Readers' comments (9)

  • Anonymous

    No comments on this one, so far.

    I read this when it first appeared, and 'what exactly would you comment on ?' was a question I asked myself.

    The only one I could come up with at the time, was the thought that if Mark had decided his daughter is now old enough to ask really interesting questions, she is probably also old enough to be at the stage when men get that 'I really don't understand her !' thought re women (which seems to be reciprocal).

    But a question itself can be interesting, even if you can't understand the mind of whoever posed it !

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  • Little One

    I think it is very hard to be a student (although I am biased as a third year, almost qualified!) and I certainly know that I came into nursing because it was a 'vocation' for me and not because I wanted fantastic job prospects and a brilliant salary.

    I do think that we should spend a lot more of our time with patients and in hospitals, as whilst theory and evidence based practice is important I feel that we sometimes miss out on the holistic approach to care, despite it becoming more 'popular'. We spend too little time on each placement to gain a real feel for certain areas of practice and the restrictions placed on students leave us feeling unprepared to qualify.

    We are not allowed to prepare, draw up or give IVs.
    We are not allowed to perform ABGS.
    We are not taught venepuncture.
    We are not allowed to perform epidural observations.
    We are not allowed to use equipment such as hoists.
    We are not allowed to perform clinical procedures such as ECGs and bladder scans on our own.

    Whilst I appreciate that many of these things are technical and 'advanced' HCAs are able to use equipment, bladder scan, perform ECGs, do venepuncture etc and yet we are unable to be taught how to do it as a student.

    In 6 months I will be a qualified nurse and could potentially end up in an area where I am supposed to do this frequently without supervision and support, and even teach it to people in a years time! It would have been helpful to practice whilst supervised and supported as a student.

    Sorry... little bit off topic!

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  • Little One | 12-Mar-2012 4:44 pm

    It sounds totally unreasonable. Is this a question of insurance?

    It seems little point in learning all the theory if you don't spend enough time with patients to put it into practice!

    I got a job in a private clinic after 20 years experience in general medicine and working totally autonomously. We even inserted intravenous catheters into the right atrium on our own and gave intra-arterial chemotherapy on occasions. we were expected to be fully trained to undertaken any work which came our way and it was our responsibility to find somebody who was able to carry out or instruct us on more rare or new techniques which we needed. However, in this new job I was only allowed to serve meals on the ward and escort patients to the operating theatre with a porter and in the oncology outpatients I was allowed to take blood pressures of the patients when they first come in and later taken them a cup of tea. Yet the nurses were rushed off their feet.
    I was sent on a course to take blood even though I had taken many and prepared and administered antibiotics and other treatments on a daily basis for 20 years and my colleagues often sought me out, even from other wards, if they had difficulties with venepuncture. I always respected the highest standards of aesepsis. The course offered was very basic so I learned nothing new from it so it wasn't even a refresher for me. I then had to complete a practical session on the ward and then practice under supervision before I was allowed to take blood or do any iv work. This involved getting a sister from another ward but every time I asked they were not available!

    I have digressed even further but just wished to respond to Little One and point out some of the difficulties we are up against even when qualified and experienced.

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  • Anonymous

    Little One | 12-Mar-2012 4:44 pm

    One of the points the BBC3 series about new F1 doctors made very clearly, was that they were starting work before they had become competent in taking bloods, etc: in fact, 'I didn't think I really knew what I was doing' and 'Only now, 3 months in, am I starting to feel like a proper doctor' were the type of comments they made. One even said 'I think they (the nurses) must think of me as if I'm a child' or something like that (ie as if she didn't know what she was doing).

    I think doctors and nurses, and many other people, experience a very steep learning curve, when they start the job for real.

    But it does make sense, for training to try and reduce the shock of doing it for real, as much as is possible.

    However, even 'experts' are quite often unsure, of the choices they make - in fact, if you believe you really understand everything, then you probably are not very expert ! Most people can always learn something new !

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  • "One of the points the BBC3 series about new F1 doctors made very clearly, was that they were starting work before they had become competent in taking bloods, etc: in fact, 'I didn't think I really knew what I was doing' and 'Only now, 3 months in, am I starting to feel like a proper doctor' were the type of comments they made. One even said 'I think they (the nurses) must think of me as if I'm a child' or something like that (ie as if she didn't know what she was doing)."

    This isn't the way it should be. They are dealing with invaluable and irreplaceable human lives. There is something very wrong with the system.

    If you compare these with newly qualified European practitioners they are extremely independent and autonomous from the first day they start work. In fact it is a problem in reverse as they refuse to be told anything as the have already learnt all the most up to date techniques even to the extent that they show older and more experienced staff the new working practices that must replace the old tried and tested but outmoded ones. It was so extreme that in my hospital when general management suddenly arrived without any warning or explanations and guidelines from administration were spewed out and classified in lever-arch files which filled our office shelves at such a rate we had to give up precious time with patients to clear a space for them. we could no longer keep up with the pace of change and on returning to the ward after one or two days off and undertaking a procedure the chances were that a newly qualified nurse would appear at the bedside to inform you it was no longer to be done that way and you had to adopt the new method, which if you were lucky the may explain or just tell you to go and look at the lengthy guidelines (great for patient confidence in the nurse carrying out the procedure) and something on an acute medical ward we had little time to do. If you queried it, the retort was that the directions had come from administration although they were not clinicians, and sometimes the new practice was unsafe or totally impractical or even impossible with the resources available! One example was using 20 F urinary catheters for everybody to prevent leakage and the thinner ones had been withdrawn from stock. Much of our stock disappeared at this time. These nurses rapidly took over the running of the ward from us and more or less ignored us except when there was a real emergency when they would come running to find us as the did not know how to cope. At the beginning, although i had my case load,I spent almost my entire shift in the office as every time I went near a patient I would get called away to answer mainly administrative queries and deal telephone calls, the doctors, other staff and visitors whom they were unable to answer. Trying to carry out patient care with such a high level of multi tasking was almost impossible and especially with the HCAs breathing down one's neck to criticise some little detail that had been forgotten. It seems they lay in wait for such opportunities.

    Subsequently in another job in an old peoples' home I got the sack from a job for refusing to recatheterise a resident with a 20 guage cathether even though all the old people had that size and instructions had been left for me by the boss who was on a day off! I was the only nurse on duty and the long-standing HCAs were horrified at my disobedience even though i made it clear it was against all evidence and a recent catheterisation course i had been on. On her return the boss was not at all pleased even though i used all diplomacy (and for which I am known in my testimonials) I could muster to justify my reasons.

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  • Little One

    Anonymous | 12-Mar-2012 6:39 pm

    "It sounds totally unreasonable. Is this a question of insurance?

    It seems little point in learning all the theory if you don't spend enough time with patients to put it into practice!"

    It is partly to do with insurance, because as we are not directly employed by the Trust we are not covered by their extensive insurance policies, and partly because of ridiculous knee jerk reactions to bad situations.

    To give a couple of examples, we are not allowed to take ABGs anymore because a first year student (apparently) was allowed to take an ABG on her own, without supervision, did it incorrectly and the patient bled out and died. Now, I have a massive problem with this for several reasons:
    1. Why was the StN allowed to do it unsupervised at such an early stage in her training?
    2. Why did the RN not realise that the patient was bleeding out, as there are many clinical signs, not to mention the transducer on the A-line reading funny?!
    3. Why do all other StNs have to be punished and not be allowed to do it just because of one mistake?

    Another example, we are not allowed to undertake epidural observations because (apparently) a student was unsure how to measure the bromage score correctly, didn't ask the patient if they could move their arms or legs etc and subsequently it was found that the patient was paralysed. Again I have issues with this in that:
    1. Why wasn't the StN shown how to do it correctly?
    2. Why was she left to do it alone if she was unsure of what to do?
    3. Why didn't an RN check, at any point, that the patient's bromage score was correct?
    4. Again, why have this knee jerk reaction where one StN has made a mistake and everyone else is punished for it?

    It would seem that the sensible thing to do would be to train mentors correctly to be able to provide proper supervision and training in these more technical areas, to instill the importance of asking for help and supervision into students so they do not do things outside their comfort zone without support and to ensure that students can continue to learn skills which are vital to many areas of nursing, but ensure that they are suitably trained and supported in doing so.

    Instead, now we have nurses that stick to the letter of the law and refuse to let students do it at all, you have nurses who will check you've done it before, watch you once, and let you carry on doing things by yourself and those in the middle who will directly supervise you and support you, but will let you do things. Surely this middle road approach is more sensible than either of the extremes?

    I have taken ABGs and epidural observations earlier on in my training, and now as a third year am told I am no longer capable of doing it, despite learning the proper technique and being fully supervised, and signed off as competent, at the end of my first year/beginning of second year!

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  • Little One | 15-Mar-2012 11:00 am

    it seems strange when one considers all the tasks and duties non-nursing staff are allowed to take on

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  • michael stone

    Anonymous | 13-Mar-2012 3:47 pm

    'If you compare these with newly qualified European practitioners they are extremely independent and autonomous from the first day they start work. In fact it is a problem in reverse as they refuse to be told anything'

    I also watched that TV series about junior medics, and it isn't as worrying as it sounds - because the new F1s are all so aware of their lack of experience that they do ask more senior doctors, and senior nurses, for advice/guidance. Also, the tasks given to new F1s are restricted, so that they can learn and gain confidence without (with luck) damaging anyone. It wasn't that they had not been exposed to much of the theory - simply that actually making decisions for real, isn't the same thing as answering an exam question.

    I think those newly-qualified foreign medics, who are so confident that they don't ask for any advice, would probably worry me more.


    Little One | 15-Mar-2012 11:00 am

    I think you are 100% to have those 'issues' - and everything else in that post, makes sense to me as well.

    As I have said before, there is a fundamental problem with finding the right balance-point between the 2 extreme approaches to ensuring usually competent behaviour. The two approaches are:

    1) Train people well, check that they are competent, then just let them use their expertise to do the right thing;

    2) Assume that not everyone, or even anyone, is trained well enough for 1) to work well enough, so set down simple but exhaustive sets of tick-box procedures, and in general rules, which if followed will work in most normal situations.

    The problem, is that you cannot mix the 2 approaches - and 1) works better in unusual or very complicated situations, where 2) fails: but 2) works better in typical situations IF the level of staff training and expertise isn't as high as it really needs to be.

    This one is very problematic - I can't resolve it, but I have described the issue. You get, consequently, a sort of tug-of-war: a serious mistake happens, and you get more 'rules' (ie leaning more towards 2)) and then at some point, everybody realises the rules are getting in the way of common sense, and people try to move back towards 1). But the better training and experience, does involve spending more money, etc, to achieve that - also, a reason why sometimes 2) looks appealing to 'managers'.

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  • It seems very much to be a case of where you study. Local policies differ and some students are allowed to undertake venepuncture and cannulation. Apparently, as has already been identified there appears to be a link with adverse events.
    A lot of mentors do let students do things such as BMs, as long as they have been supervised. I'm currently in the last week of my critical care placement and my mentor has no issues with me taking bloods and ABG samples from an a-line.

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