Friday 28 April 2017

Super Nurse Is Entering the Building

I’ll never forget my first year as a staff nurse, even all these years later, it was when I really learnt how to nurse and what was required of me as a nurse. My nurse training had been hard, I was expected to learn so much and cram in so much information in what felt like such a short period of time. But during this time I was also sheltered from responsibility, “Student Nurses can’t do that,” “Student Nurses aren’t allowed to do that,” “Just sit there and watch me do this, you’re only a Student Nurse.”

Then, suddenly, I was a qualified Staff Nurse and all that sheltering was gone. I was a Staff Nurse, I was expected to know what I was doing, I was given the ward’s drug keys, I was solely responsible for the patients allocated to me, I was responsible for all my own actions. In that first year after qualifying I learnt so much, so many different things in such a short time. I learnt how to really use my nursing skills and understand what is required of being a nurse. It was a very important time for me, and for many nurses I have spoken to.

As my first year of qualifying ended, as I settled down into my role then I learnt new skills, such as giving intravenous drugs, managing central lines (intravenous lines going a major artery of the heart), and later still taking blood and cannulising patients. It was the confidence and experience I had gained in that first year that enabled me to learn these new skills and safely practice them.
The Nursing and Midwifery Council (NMC), the regulatory body for nursing in Britain, are looking at changing nurse education, again. They haven’t formally announced it, there is no consultation open on the NMC website, but the Nursing Standard had access to the unpublished plans, Standards for Registered Nurse Education, reported on them (1). These proposals would see student nurses having to learn a whole new set of skills before they qualified, skills that nurses learn now after they have qualified.

The NMC wants newly qualified nurses to be able to:
  • Prescribe from a “limited” formulary, a selection of drugs and dressings; 
  • Cannulation; 
  • Venepuncture, take blood, 
  • Management of continuous infusion of intravenous drugs and fluids and safe use of infusion pumps, safely giving IV fluids; 
  •  Injection (bolus or push) of intravenous drugs, giving IV injections 
  • Intermittent infusion of intravenous drugs and safe use of infusion pumps, pumps with variable dosages such as insulin pumps; 
  • Subcutaneous administration and safe use of syringe pumps, such as syringe drivers; 
  • Subcutaneous infusion of fluids.

Nurses already do all of these clinical skills but these are all skills that are learnt after qualification. They are all complicated clinical skills, if carried out wrong they could be very seriously harmful to a patient.

If the NMC wants student nurses to learn these skills they will need to provide the resources and time for them to learn them and have their competencies certified. You can’t just learn these skills in a classroom and then go out and practice them on patients, you need a skilled and experienced nurse to sign you off as competent.

This requires a large number of suitably trained nurse mentors, who also regularly practice the skills the students are learning, with the time to teach and access the students. But mentoring student nurses at present is proving difficult. 9% of NHS nursing posts are vacant (2), and nurses’ workload have hugely increased (3), which has had a detrimental effect on student nurse placements (4). Mentors are not getting enough time to teach students (5), students aren’t getting enough practice time, mentors have to do mentorship duties in their own time, and some departments/placements are no longer having student placements because they are too busy and short staffed (4). This before any changes to student nurse training are made, changes that would require even more mentorship involvement.

Also, will student nurses even get the chance to learn these skills in practice? I mentor second year student nurses, in my job. They spend four weeks with our team on their community placement. Many of them have had little or no experience of wound care and administering injections. This is not their fault, this is due to the nature of their placements, many of them are not getting the experience for their learning requirements now.

Working on Medical and Surgical wards student nurses could get experience of intravenous infusions and injections, they are certainly used a lot, they may even get experience of intermittent infusions, but subcutaneous infusions and pumps are used rarely, if ever in hospital. They are more often to be used in end of life care, which is happening more and more in patients’ homes. I often set up and manage subcutaneous pumps, but it is not something I can guarantee every student nurse I mentor, we do not always have an end of patient life on our caseload.

Nurse prescribers are out there and are making a difference but nursing prescribing is still a skill the profession is only just learning to use. Are there enough nurse prescribers to mentor nurse students in prescribing? Currently there about 55,000 nurse prescribers (6). This may sound a lot but, as of November last year, there were 340,384 nurses and midwifes employed by the NHS (7), this means only 16% of nurses are nurse prescribers, and I would be concern that not all of them are also mentors, and many of them will be specialist nurses who students rarely have placements with. So again, who will mentor student nurses in prescribing?

The first cohort of Associate Nurses have started their training (8), and this does feel as if the NMC is hurriedly trying to draw a difference between Registered Nurses and Associate Nurses, without understanding what is involved in clinical nursing. Associate Nurses are designed as much more hands-on nurses, they are not being training in the assessment, planning and evaluation side of nursing that Registered Nurses are expected to do. Put bluntly, Associate Nurses will implement what the care plan says, but Registered Nurses will still be needed to assessment what care is needed, plan that care (The care plan) and evaluate that the care is meeting the patient’s needs.

Instead of purely focusing on clinical tasks, why isn’t the NMC looking at what is required for each role at qualifying?

In my opinion, based on my own experience of being a Registered Nurse (both a newly qualified Registered Nurse and as a Nurse Mentor supporting newly qualified Registered Nurses) at qualification as Registered Nurse should be able to:
  •  Safely administer medication (whether Drugs Rounds in a hospital or in patient’s own home),
  •   Safely administer medication via injection, either subcutaneous or intramuscular.
  • Safely discharge a patient from hospital (know when a patient needs support at home, whom to refer that patient to and how to do it),
  • How to carry out a patient assessment, whether on admission or during their episode of care
  • How to plan and evaluate a patient’s care,
  • How to prioritise patient care during a shift,
  • How to coordinate a shift,
  • How to prepare and recover a patient from surgery safely,
  • How to safely administer a unit of blood to a patient
  • How to assessment a wound, and to know when a wound is caused by pressure damage.
These are skills much more to do with managing care and assessing a patient’s needs, but these are skills that are essential to newly qualified Registered Nurses, I did not have all of these skills when I qualified, and had to quickly learn them in that first year after qualifying.

I have a low opinion of the NMC (Read my blog about Pauline Cafferkey and my two blogs about Donna Wood to see my full opinion) but this latest “radical” change to nurse education (1) is just another example of what a poor organisation they are. The problem at the heart of this plan seems to be a lack of understanding of the role of the Registered Nurse, and this seems to be because so many people employed by the NMC have little or no nursing background. The prime example is Jackie Smith, the NMC’s Chief Executive and Registrar. She has no background in nursing, her background is the law (9).

When are we going to get people regulating nursing who have a background in nursing and who understand what is involved in nursing? Then maybe we would get less of these “radical” changes that do not reflect what is needed in nursing, and more policies and regulation that moves nursing forward into the modern healthcare profession that it needs to be.

Drew Payne

Friday 21 April 2017

Jeremy Hunt: The Man Who Doesn’t Understand Nursing?

“If I put money into pay, it would be hard to increase doctor and nursing numbers.” Jeremy Hunt (1).

At a conference for senior nurses, last month, Jeremy Hunt made the above statement. He said he “dearly” wants to increase nurses’ pay but he just can’t, resources are too tight. He was basically saying that we, nurses, have a choice, a decent pay rise or more nurses working on the wards, he can’t do both. This is emotional blackmail at its worst. He should be ashamed of himself for trying to guilt people into accepting his own harmful policy, and for lying.

He is lying because it is his decision what pay rise nurses receive, he is the Sectary of State for Health. I, as a Community Nurse, have NO SAY over my pay rise. Nobody came to me and said, “You can have a pay rise equal to inflation but the five empty poles in your team will go unfilled.” I was never given that chose, even when Hunt is trying to use emotional blackmail to imply it is the only choice. Even for him it is not the only choice.

NHS resources have been cut to the quick. Since 2010 NHS funding has only increased by 0.9% a year (2), well below inflation and obscenely below the increased demand on the NHS. But Hunt is the Sectary of State for Health and could be making special petitions to the Treasury for more funding, he could be lobbying the Chancellor for a realist increase in the NHS budget, Hunt is a member of the Cabinet (3). But instead he does nothing, and when faced with angry nurses looking at another real term cut in pay, says his hands are “tied”.

Hunt says he “dearly” wants to give nurses a decent pay rise, but his previous actions show the opposite. In 2014 he vetoed a 1% pay raise for nurses (4). At the time he claimed that the NHS couldn’t afford this measly pay rise, and that it would lead to the loss of 15,000 nursing posts to pay for it (5). Hunt’s argument sounds all too familiar. Yet after industrial action, Hunt did a climb down and we got that 1% rise (6). Strangely enough, the NHS didn’t sack 15,000 nurses to be able to afford it.

But why does nurses’ pay matter? Because of the high number of nurses leaving the NHS. Last year there were 23,443 empty nursing posts in the NHS, 9% of the nursing workforce (7). Last year 5% of nurses did not renew their Nursing and Midwifery Council (NMC) membership (8). All Registered Nurses have to be registered with the NMC to work as a Registered Nurse, if you do not renew your membership you no longer can work as a nurse, or you no longer want to work as a nurse. There also has been a 92% fall in EU nurses coming to work here since the Brexit Referendum (9).

With such large numbers of empty nursing posts Hunt should be doing everything he can to fill them, nurses are the glue of healthcare because without us the vast majority of patients would not receive the treatment they need. Yet Hunt seems to be doing everything to increase those empty nursing posts. Nurses’ pay has fallen in real terms by 14% since 2010 (10), while MPs’ pay has increased by 14% since 2010 (11).  This has seen a 50% increase in nurses applying for hardship grants since 2010 (12), grants to help nurses pay household bills and mortgages and for travel to work, the essential things of life. Last year alone £250,000 was paid out in hardship grants (13).

The NHS is haemorrhaging experienced and well trained nurses. At the same senior nurse conference Hunt spoke about this, but his answer left me dismayed. “We need to think about new ways into nursing,” Hunt said (1). Instead of looking at keeping nurses in nursing, his attitude seems to be “Just find me some new ones to replace them.” Why isn’t he valuing the experienced nurses he has? A newly qualified nurse couldn’t simply replace me, with the best will in the world they would not be able to do all the clinical work I can. They would need the years of training and experience that I have been fortunate to accrue. The NHS needs nurses like me, especially as we face increasing demand from increasing unwell patients. Hunt needs to ensure the NHS keeps its experienced and well trained nurses, so why isn’t he doing this?

Retention of staff is about pay and conditions, is about keeping staff working for your organisation. How does cutting staff’s pay in real terms by 14% (10) while their workload increases year on year encourage people to stay in their jobs? How can Hunt think this is a rational way to run an organisation like the NHS? He cannot reply on the false idea that nurses are “dedicated” and therefore will work for low pay. Nurses need to pay the bills as well, and are leaving the NHS in droves to find better paid work. What will Jeremy Hunt do when there aren’t enough experienced nurses left to safely deliver patient care? How is this man still Sectary of State for Health?

Someone has published on Amazon the book Everything I Know About Nursing by Jeremy Hunt (14). It consists of 100 blank pages and nothing else, and it sums up so much of what I feel about Hunt. At the coming election I can but hope that Hunt will lose his seat and the NHS will be finally free from him. Unfortunately Theresa May would probably appoint someone just as awful and arrogant as Hunt to replace him, the NHS is such a low priority to her.

Drew Payne

Thursday 13 April 2017

A Spoonful of Sugar

In my Trust’s staff canteen you get a subsidy off hot food (Including deep fried chicken and chips) but no subsidy for cold food (Including all salads and sandwiches). Which foods do they encouraging me to eat more of?

NHS England has announced that it wants to cut NHS staff obesity, and to do that they want to cut the consumption of sugary drinks in hospital, even banning the sales of them (1). It is recommended that we get only 10% of our daily energy intake from sugar, which equals 70g of sugar for men and 50g for women (2). A can of Old Jamaica ginger beer contains 52g of sugar, Coca Cola and Pepsi contain 36g (3). It is easy to see how these “full fat” drinks can surpass our daily sugar intake in only two different drinks, and that’s not counting the sugar found in our food.

NHS England claims that 700,000 NHS staff who are overweight (1). They say that because this affects people’s personal health it also increases rates of sickness (1). The NHS does have a problem with sickness. The NHS sickness rate, for last year, was 3.93% (4), which does not compare well to the national rate, for the same time, of 1.9% (5). Now all this sickness cannot be blamed on staff’s waistlines, even though it is always a good escape-goat. The high workload levels in the NHS and the ensuing stress levels surely have an effect on sickness rates.

The NHS has become an increasingly more stressful place to work. Cuts to resources and funding (in real terms), staff shortages (there are now 21,205 empty nursing posts in the NHS, 10% of the nursing workforce (6)), and increasing demand on NHS services (patients attending A&E Departments has increased by 6% in the last year (7)). It has all had a detrimental effect on staff. An RCN survey found that many nurses were too busy to take their breaks during a shift, or were even drinking enough water to keep hydrated (8), and this was happening right across the NHS, not just in emergency care. Yet it is a legal requirement that workers have three breaks during a shift, at least one being a twenty minute uninterrupted one, if we work for six hours or more, as part of working time regulations (9).

As a Community Nurse, I have forgotten the last time I took my lunch break, I am just too busy to do so. I come back to our office, after a full morning visiting patients, and immediately start my patient follow-up at my desk (Ordering medications and dressings for patients, referring patients to other services, catching up on my paperwork). Because I have afternoon patient visits this is the only chance I have for patient follow-up, my lunch break. Therefore my lunch is snatched at my desk, because of this I need food that is easily eaten, sandwiches and bottled drinks. I am not the only nurse who does this. When lunch has to be snatched then it has to be something quick and easy to eat, processed and fast food provides this, even though they are not the healthiest of options.

Banning or surcharging sugary drinks might be a step in the right direction but it is only a small step and not the complete solution for improving staff’s health. Management could take much more sweeping measures to help make staff’s working environments make them more healthy, such as: reducing workplace stress, being realistic with workloads and ensuring staff are not regularly over-stretched; make breaks compulsory and ensure staff take them, and provide staff rooms away from the clinical area for staff to take their breaks; encourage training away from the clinical area were staff can keep themselves up to date; and provide staff with decent on site gyms. There is a lot to be done to promote staff health. And this shouldn’t be done because staff are “role models” or just to reduce sickness, it should be done to benefit staff.

Of course even if they do ban the sale of sugary drinks in hospitals this will have no effect on many NHS staff’s lives, those who work in the community.

What leaves a cynical taste in the mouth is that this is the cheapest and least option they could do, banning the sale of sugary drinks. It costs nothing, would be easy to implicate and could actually generate positive publicity. Aren’t we, NHS staff, worth more than a cheap stunt? The NHS’s staff are its biggest resource and yet our well-being seems to be of a lower priority then painting hospital buildings. Who cares about NHS staff, not the NHS?

Drew Payne