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formally announced it, there is no consultation open on the NMC website, but the Nursing Standard had access to the unpublished plans, Standards for Registered Nurse Education, reported on them (1).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


Unknown said...

You are talking complete sense. It's people like you that should be working for NMC. It makes one's head spin when you think of all the skills and knowledge a Registered Nurse needs plus experience, worrying that now we're adding NA's to the mix how Students will be mentored and HCA's supervised. We'll be doing this as RN's on our pin number as we will be delegating to increasing numbers. More responsibilities but not more remuneration or respect.

Drew Payne said...

Alexis you are very right (Accept the part about me working for the NMC, NOOOOO!! They would sack me after a week anyway). As nurses, we are so often responsible for organising patient's care. Shame NMC has no clue about this.

Unknown said...

I agree completely. I actually have developed an anxiety disorder since qualifying and am on medication I was signed off work for 8 weeks less that 12 months after qualifying as the stress and pressure of the responsibilities was too much. Basic skills for new nurses are what's needed. And I done a 6 month module to be a nurse prescriber aswell as numerous exams and case studies. Many competencies that the NMC are expecting are completely mad and putting patients at risk. IV administration and cannulation as well as venepuncture are all additional skills that should be understood and supervised accordingly once qualified and after preceptorship and with sufficient support from a preceptor and a well managed PD team. We teach student about sub cut continuous pumps and we supervise them doing it but only if they are confident and competent and understand what they are doing fully.

Drew Payne said...

Kirsty, I am so sorry about your experience but you are also right. These are complicated skills and shouldn't be treated lightly, "oh a student can learn that in an afternoon" attitude. People need to be given the space and support to develop these skills. We need skilled and competent nurses for good quality patient care, not nurses rushed and forced into performing tasks.