The Memory By The Sea.

On bicycle they raced towards the sea,

Such a rare day, a blue fair day.

His hair was as swept as the waves was hers.

The ocean stirred her whole World,

And whipped up her thoughts in the air.

For he was her World and she loved him.

 

Road was narrow and bikes so close

On this rare day, a blue fair day.

That metal nearly crashed against metal,

Like waves against rock.

But they laughed, sped away and rode on.

Such a lovely World and she so loved Him.

 

They arrived on the shore line,

For this rare day, a blue Fair day.

She could hear the music in the sea,

He clutched the bottle, like the voice of the breeze,

Such treasure lay within,

From this lovely World. Oh how she loved him.

 

They tossed the bottle into together.

On this rare day, such a blue Fair day. 

The four treasures was theirs to hold,

Remember and then let go for the sea to unfold.

Such a memory to have, to cherish and to own.

From this day, oh how she loved him.

 

 

So the memory lives on by the sea,

On such a rare day, a blue fair day,

Thoughts linger down the years,

Like foot prints upon the cliff, like tyre marks on the sand.

As they rode off together but not hand in hand.

For he was her World and she loved him.

But unbeknown then, sadly he did not love her in return.

@onethoughtfulwoman February 2013

The End Of My Nursing Days.

In my twilight days of nursing there saw an introduction of a laptop computer. We all had one provided and training on how to use it. Those days had seen our area of work extend and staffing cut. The laptop had one very important function: to record data. This is what we all had to do. My area of work was then in the community, so I travelled a lot, covering many miles sometimes between two surgeries caseloads and in all weathers.

Every detail and work entry had to be recorded on a system called System One. So that meant that every phone call, procedure, paper work, (EG, if it involved an referral or assessment), was logged. This had to be done for every patient visited. The time we took to do each thing and how long it took to get from one patient to the next. This was logged in our work dairies and then onto System One. You still had all the patients personal records of care to do in the home as well, I might add. This was asked for to help see where the workload was, for accurate records of patients, and to prioritise resources.

You can imagine that this was a lot of work and when we could not get it done in the days schedule, it had to be taken home to do it. We were all given the appropriate connections to the data base to get this done. At the same time, my e-mail box was forever getting fuller. New policies, training, forms, referrals and memos. I personally was finding it harder to keep up. Sometimes, my brain was a fog and the effort to juggle the balls was becoming harder. My own personal stress levels went up and I felt vulnerable. Vulnerable that I would miss something, forget something. I had a note book and wrote everything I needed to do down so everyone got seen, every task and communication done. My tick list was ticked off at the end of the day and shredded. I worked incredibly hard but the passion and the enjoyment went to a very low point.

It was like being a hamster on a wheel. The harder you ran, the harder the wheel turned and it just went round and round, always to the same place, never to finish. Because the hamster was always running and the wheel just ended up at the same point for you to run all over again. It felt like you were getting no-where.

Sometimes, a ray of energy would emerge. A really excellent job was done, you had made a difference to someone’s life and job satisfaction prevailed. You were happy and pleased and felt it was all worthwhile. But, like the hamster, the next day you were back to just running, eventually you burn out and that is what happened to me.

In the end, I had had enough. I had done all that I could do. I knew that there was no end in site to any of it, if anything it was going to get worse, and I have been told that since then it has got worse and I am well out of it.

But I took 28 years of care with me and it was brave decision but I just said no-more. I thought, as it had been my identity all my working life, it would be hard to let go. But it hasn’t been. Now, my new life working in a school as a teaching assistant has made me so happy, opened up so many new doors. I have never looked back. I go to work each day never having the dread or the worry. There is no stress and if there is it is very minimal.

I had some wonderful times, happy memories, really dark days, sadness and some regrets. But I did something worthwhile and I did it well and for that I am proud. I have written these blogs to defend my former profession. I could not just sit back and let the recent press hound us in such a way, without trying to defend those still brave enough to work in nursing.

I would say to the general public one thing. Come and do a shift. Put a uniform on for a day and live it with us. See what it is like. I am not defending shabby care, hostility and I am not minimising the pain that bad care has caused to families. I feel ashamed that such cases have existed. But the general public just has to know how hard and almost inhuman it is to be asked to just keep going, like we are now asked to do in such work conditions. This is the vital message I want to convey to any reader out there.

Later this week: a summary of what has gone wrong, given what I have discussed here and what can be done now if at all?

Government Policy And The NHS.

When something is going wrong in a system of work,fingers naturally will often point to the management structure. Senior staff can be questioned, managers decisions criticized.in this case with the NHS, the biggest manager and where the buck totally stops, is with the Government of the day. They have the overall say in how our NHS is run.

I am no expert here on figures and am not a statistician . What I can say can only be based on what I have seen for myself and read in the media. So let’s take the Mid Staffordshire case. The horrific situation of systematic failings in care was largely created by a catalyst of cost cutting and the relentless drive towards becoming a Foundation Hospital. In order to become that,(foundation status means more self-governing) the hospital had to slash debt, have improved performance targets and be seen to be keeping on track, not only in budget but what it could show on paper to be improvements, efficiency and throughput.

In-fact, this objective is part of every hospital up and down this country. Along with this, the Private Finance Initative called PFI’s was introduced by the last labour government and its impact have made the present situation even worse. PFI’s are loans to hospitals to rebuild, improve and to makeover old hospitals into shiny, spanking new ones. However, many of us will know the outcomes of hospitals struggling to pay off these loans. They have been left with huge debts and deficits.

Then, on top of that, we have fines if certain targets are not met. If a patient goes over a four hour waiting time to be discharged from the Accident Emergency Department to a ward, transferred to another unit or sent home, the hospital is fined. If an ambulance does not deliver and dispatch a patient in a certain time span, it is fined. This is all supposed to be about improvements in performance, get the stick of financial punishment out, and somehow magically results will be produced forthwith. But what has happened? As wards shrink in size, as hospitals slash inpatients beds and staff to save money, there results in a chaotic rush of bed juggling, and the frantic efforts to free up beds against fewer manpower resources. If a patient is discharged and then that patient is what we would term a “bouncer”, that is to say they are re-admitted within a certain time frame,the hospital gets… you guessed it, a fine!

How are hospitals suppose to stay on track budget wise if all they are threatened with is fines? This is government policy now and it is doing nothing to help patients with their care.Infact, this only creates more pressure to treat a patient as a price tag, a unit, a juggling ball on a bed; and leads to what we have heard about bed moving in the middle of the night, against the tide of complaints of sleep deprived patients on wards. It’s like musical beds. Patients become little more than another stat to be got through the system as quick as possible. Now we have jobs purely for bed managers and early discharge assessors and the term, the “bed- blocker” comes to my mind. This is when someone is stuck in the system with no outlying community bed to go to ( because they have been either cut or closed) but they can’t go home either.

Never has the pressure for beds and timed targets been so great as it is now; with increased population, sicker older people, increased expectations of the population to be seen and treated and the changes in GP’s out of hours care. Literally hospitals are fit to bust…..

I leave you with a question. How can these government-led poliices be conducive to quality total patient care? And the nurses, as well as other NHS staff, are caught right in the middle of it. I tell you something: it makes for a hell of a lot of stress. It does nothing to help health-care professionals, with their own mental health, who are suppose to be angels or compassion, care and tranquillity, when really they are tearing their hair out, to give this essence of care that is talked about….

Tomorrow: An example of the crazy burden of data collection and why ultimately I left NHS Nursing.

Good Leadership Skills Within the NHS: Are They There Or Not?

During my nursing career of 28 years within the NHS, I worked with only three exceptional leaders of people. Two of those leaders worked together in the same unit. One was senior to the other and both worked in harmony together. It was some of the golden days of my NHS life.

When you have a good boss, it shows through and through. You feel valued, invested in and your opinions matter. There is a fairness and compassion within that person. They are interested in people, usually are highly skilled and experienced in their field and have a humane and caring character. They have disciple within themselves and enhance and encourage that in the workplace. The atmosphere in the place of work is happy, standards are high and efficiency prevails. When you are asked to perhaps stay late, or to help in a crisis of staffing, you will come forward because you invest in your workplace, in return for how you are treated. Well, that was how it was for me anyway. 

Sadly, overall leadership within the NHS is poor in my opinion. There are good leaders in the NHS of course and these ones stand out. However, a good leader is often challenged by higher management, if they are not a “yes man” and not always popular with that seniority. In the end these people leave and go on to other positions, leaving the vacuum and the loss behind. Poorer management often comes in as a result and then staff leaves and recruitment/retention gets harder. Moral goes down: stress goes up.

I think one of the problems for nursing is a lack of experience in leadership. Historically, to become a ward sister, at one time, you needed to be qualified for five years.

This is now a dreadful statement to make but I have heard someone say once, that nurses are like “painters and decorators”, you climb the ladder so fast that you scarcely come into contact with any patients. This is a simplistic and rather brash view, but the point here is that, I personally feel that the quality of those in charge, in terms of interpersonal skills with people, CAN be lacking. There just isn’t that core backbone of personal standards, discipline and integrity that there once was.

Then at the heart of the matter, combine these factors with nurses who do not feel listened to by higher management. They feel dis-empowered, that no-one really cares and that they are just a number, easily dispensed with and easy to replace. Challenge anything with anyone who is in a higher position than you and you will often come out worse. Employees can easily feel start to feel vulnerable. Conflicts and bullying are present in the NHS, just as they can be in any large employing organisation. Staff feel threatened and gagged if they dare to speak out. Confidentiality clauses are cited as a means of fear to shut people up for fear of losing their jobs or being frog-marched up to the NMC ( Nursing, Midwifery Council) professional conduct committe. Nurses are in a terrible dilemma if they feel standards are being compromised, yet have no confidence in any leader to talk to or simply feel too afraid. They trust no one. Both the Royal College of Nursing and the NMC have issued guidelines on how to whistle-blow professionally but too few are still prepared to blow that whistle at a local level with a mortgage to pay.  

Finally, it is in my view that the NHS also operate within a very rigid and hierarchical structure. Everyone knows their place in the pecking order from cleaner, to porter, from nurses to doctor and consultants. There is less snobbery now between those at the top of the management tree to those at the bottom; and nurses are no longer seen merely as doctor’s hand-maidens due to their increased technical and skilled roles. Thankfully, there has been this shift ( enhanced by our increasing number of graduate nurses) but both leadership qualities and this persistent hierarchy remains an issue……

On Monday: Management decisions at the very top- Government policy. How PFI’s and the obsession for targets and figures are critically wounding our NHS.

 

 

 

The Role of the Qualified Nurse. Past and present

When I qualified I remember what was then called ” task-orientation.” We started in bay one and went, in two teams, up and down the ward with our care and our trolleys. With aprons on, we washed and turned, fed and hydrated our patients. Every chart was filled in, everyone seen, mobilised, toileted. Dressings were done,medication was given and when that was finished we went off to separate breaks ( one team at a time) and then came back and started it all over again.The ward sisters -there were two of them had an eye on everything. Nothing was missed and woe betide you if it was missed. The ward sister was the heart and the nucleus of everything. Doctors went to her, everyone went to her. She often took the phone calls. She managed everything. I was lucky as I was on a strict but excellent ward in terms of care. There was no shortages of nurses wanting to work on this ward.

However, task orientation was criticised. It was not giving personalised, individual care. People were not a set of tasks but with unique and differing needs. The regular “Kardex”, as it was called then, of writing up the care was changed. Up to this point it had been short and concise. An idea from America came to our NHS,it was shaped on the Roper’s Model of Care:it was called the Nursing Process. This was the first of the mountain of paper that emerged.It meant that all patients had to have an individual care plans for every activity of living. These were first hand written and then when I left nursing they were typed photocopies and had become little more than tick-boxes, another task in my opinion.

Then something else happened which changed our role. Doctors were working sometimes 80 hrs a week, being on call etc and this was rightly considered too much, something had to be done. With this concern came an increase in technological advances in care. Patients who might have died now lived with advancing medicines, diagnosis and procedures. Slowly, the nurse practitioner would be born out of all of this. However, in the mean time sisters were becoming bleep holders, budget holders and bed managers. Staff nurses became clinical shift leaders and I was told to take my apron off and start running the ward instead. There were still qualified nurses and nursing auxilaries doing the care, but what was once undertaken in a higher dependency unit was now becoming mainstream on the wards. This was very marked for me when I returned to acute nursing after working for four years in elderly care rehabilitation. The work load even by then was becoming more stressful.

So registered nurses paper-work increased, more advanced skill became the norm, including venepuncture, cannulation, IVI drug administration to name a few. Hotel workers replaced nurses both qualified and unqualified in giving out meals and drinks. The nurse mentor was born and he/she was now responsible not only for patients but for students as well. This was all happening when I left acute hospital nursing in 1993. I left and went into community after a particular night when one visitor came up to me and said:

” Hello again, there are two things I observe about you. One is that you are always here and two you are always writing out bits of paper.”
It is now 2013 -20 years has passed since then.

Now multiply what I have said a few times more, as demand for services, changing clinical roles, paper, stats, sicker older people, European Economic Community patients needing care, cuts in resources, cuts in staff and you can begin to see why we are in the current crisis situation. Also, crucially from the very top of the decision-making tree, our government and senior NHS management, who increasingly see patients as a entity of profit-making and not focusing on them first as someone needing care. No wonder the Government is stating that it is costing just all too much and auctioning the whole care parcel out to who ever can give the best price…..

Tomorrow: Let’s start to look at leadership within the NHS.

So What Improvements do We Need to Student Nurse Education?

Today, I want to discuss two points in relation to student nurse education. (Please bear with me as this has to be a longer blog post today to get the points across.)

It has been suggested by the Government that before an individual embarks upon nurse training that they should spend one year as health-care assistants so that they can learn compassion, care and have a better grasp of the basics of nursing. I would pose a question to you, as one who now work in education. Would you say that in order to train to be a teacher you have to become a teaching assistant first to understand children, their needs and how they might learn more effectively? No-one is suggesting this, so why nurses.

Yes, it can be strongly argued that having some ” grounding” in a care setting is helpful in giving you an edge, a valuable insight and knowing if nursing is for you. I can’t argue against that. I, for one, was a nursing auxiliary for ten months prior to student nurse training. However, many potential student nurses attending interview have done just that.It’s seen as having a possible advantage in being offered a place, if you have worked in, say a care home or as a nursing auxiliary. Yet, certainly when I was nursing ( up to 2010) there was an emphasis on basic-care needs that had to be met in order to pass one’s placement. Teachers learn to be teachers with one years post-graduate qualification after a first degree. Student nurses take three years. I would argue that student nurses have enough time to learn to be registered nurses if the quality of the theoretical and clinical teaching they receive is safe and effective. Any prior experience before this is very desirable but not essential.

This brings me to the second point and a potential flaw in the current system. The clinical teaching and assessment of student nurses is now in the hands of registered nurses themselves, mostly by staff-nurses working in an unit or ward. Many nurses are inspirational and dedicated teachers but many are not. Historically nurses have not been taught to be teachers in the same way that teachers have not been taught to be nurses in school. Teaching is a skill. I must add here though, that in order to be a mentor, nurses have to be qualified for at least one year and then go on to pass a three month teaching and assessing course at level three( degree level). In practice even with this, teaching quality can still be very varied. Personally, I loved being a mentor and felt that I gave the support and teaching that student nurses needed. I was passionate about it and did my very best. Every student nurse knows that a mentor, their attitude towards them and what they can provide in knowledge and experience, can make or break a placement. Every student nurse told me that, and I learned that first-hand again when I was a student midwife. 

Also, we now have what is called sign off mentors. So at the end of the students training their last placement has to be signed as passed and fit to practice by a sign- off mentor. This is not a clinical tutor but again a registered nurse. For me this was a half-days training on the paper work and the seriousness of what was being asked of, for those who were doing the signing off. That’s a lot of responsibility and means that the quality and safety of all the placements assessments have to be there, right from the word go!

Mentors know how hard it is to give the time, care and attention to student nurses in a busy and packed ward with stretching workloads and demands on time. Students stick to them like glue as they pursue their work, teaching on the spot and on the job. Most do their best. Lengthy student assessments have to be completed. Standards of assessments are much more rigouress in today’s nurse education. For me, back in the 1980′s, it was four small pieces of paper and tick boxes of accomplishments graded from outstanding to poor, now there are pages and pages of it. I am not saying the tick box was best practice either but I am making the point that, in theory, the standards of education are there but in practice it can vary widely from placement to placement and from one nurse mentor to the next.

Therefore,I would like to see the return of qualified clinical tutors in the work area working alongside mentors, supporting and helping them teach and these tutors easing the workload by taking charge more of the students and directing them in clinical area activities. Then I believe we can see the clinical quality of student nurse education improve…..

 

Tomorrow: moving on to being a staff nurse on a ward. What it was like for me. What I did back then and what staff nurses have to do now.

 

The Student Nurse.

Let’s begin with my training back in the early 1980′s. When I was training to be a nurse, most of my experience was gained in the clinical area. We were part of the numbers, were employed by a hospital and was paid a modest wage. The ward sister was responsible for our end of placement reports and oversaw our educational,supervision whilst on their ward or department.There were clinical tutors who visited us regularly. They were on-site at the hospital, as there was a School of Nursing attached to that hospital. They came on to the wards and helped us learn to do a bed-bath properly. We were reminded to change the water, the first bowl for the hands and face, the second for the body. Mouth care, eye care, hand care and even hair washing was taught both in the classroom and on the wards. Even now, I remember that to wash the hair the bedhead would need to be taken off first. Who has had their hair washed by a nurse whilst on bed rest recently?

There were four assessments that had to be passed. One of them was called total-patient care. This is where you were assessed solely on the care of one patient or a small group of patients. This meant that all elements of care had to be considered. Clinical observations including blood pressure,fluids, charts, dressings, medicines-everything. A tutor from the School of Nursing or senior nursing team on the ward would be responsible for that assessment. We were all nervous of course and I remember mine to this day. For me, I was in ITU at the time and looked after the cardiac patients.

Then education for nurses changed. Project 2000 came into force and this was the start of the nurse being seen, not as a pair of hands but a student and supposedly supernumerary- not counted as one of the shift numbers. Nursing was becoming a profession that first saw the Diploma of Higher Education qualification and then onto the graduate status. Why? Well, this was to reflect the growing complexity of the role and to give the profession more status as a profession.Schools of Nursing were moved to Universities and the clinical tutors became redundant. There was to be more theory taught. The terms evidence-based practice was part of the new terminology for care and this was led by current research.

Let me stop there and say this, which may surprise some of you. I am all for a graduate profession. The reasons why will be discussed in another post. While, I accept you do not need a degree to wash patients,I am totally behind seeing a workforce who questions the care they give and why they do it based on the best quality research available. Learning a skill is not enough in 21 st Century nursing. It needs to go a lot further than that if we are to deliver safe and effective care. The increasing advanced skills we are asked to do and the complex conditions we now treat, where sometimes several pathologies have to be considered is another reason……

Tomorrow: So what needs to be addressed with student nurse training? And why sometimes student nurses do not feel supported as they move towards registration as a qualified nurse.