A contribution to 2020health’s recent report ‘Too posh to wash? Reflections on the future of nursing’
By Jenny Aston, Advanced Nurse Practitioner; Chair RCN Advanced Nurse Practitioner Forum; Chair Nursing Group RCGP General Practice, Foundation Sawston Medical Practice
Nursing has received very poor press recently and much of this is due to criticism of what are rightly seen as the basics of Nursing; respect, dignity and compassion. Our profession no longer appears to care in a way that was once seen as fundamental.
Compassion and vocation – the culture of Nursing.
The image of Nursing and nurses’ place in society has radically changed over the last 30 years. Nursing is no longer seen as a vocation and is rarely a first career choice for school leavers. Those with A levels now have many more choices and the calibre of entrants appears to have dropped. Many students enter nursing after many years in other jobs and arrive with attitudes and behaviours which are hard to change. The portrayal of nurses in the media has done nursing a huge disservice. Hospital uniforms confuse patients by making it hard identify who is who. Patients used to know that sisters wore blue and doctors white coats. Modern materials tend to make uniforms look functional rather than smart and as a consequence nurses take less pride in their appearance. Nurses are also often seen in the street wearing uniform, which raises patient fears about cleanliness.
Nursing is no longer seen as a good job with prospects. ‘Would-be’ recruits are put off nursing by the lack of a career pathway, low pay and job uncertainty. Those who wanted to remain at a particular level such as Enrolled Nurses, were valued for providing a stable workforce. Today students entering nursing often have other responsibilities such as partners and children. Accommodation and travel to work, as well as surviving financially are more complicated than when most nurses stayed in hospital accommodation and walked to work.
Have we over qualified yet undertrained?
Greater emphasis is now placed on the academic learning of students. Whilst it is necessary to prepare students to manage increasingly complex medical conditions, it is also essential to teach the softer core nursing skills. There is sometimes too much focus on the knowledge rather than on attitudes and behaviours. With university based training, considerable responsibility is left with the placement mentor to ensure that students have the necessary hands-on nursing skills. Many students have minimal one-to-one learning from their clinical mentors, who are busy with their own responsibilities, and have little or no protected time to teach the essential skills. Trainee registered nurses now learn many of their skills and attitudes from unregistered Health Care Assistants (HCAs) whose training is hugely variable. In the past students learnt from more senior students, staff nurses and Clinical Teachers who worked with students on each placement. Clinical Teachers provided an invaluable link between the theoretical and practical skills and were able to assess student’s competence as well as address any attitudes or behaviours which might need adjustment. University lecturers rarely have the time to visit, let alone work, in the clinical areas.
Good nursing involves carrying out a set of care tasks, assessing the patient as well as addressing the patient needs as a whole. One reason why patients feel uncared for is the fragmentation of care which has resulted from the delegation of tasks to HCAs. Although it may be sensible to delegate things like washing and feeding the result is that trained staff spend less time directly with patients, so subtle cues about a patient’s condition may be missed. Trained staff are therefore increasingly reliant on second hand information about patients. In the past a significant percentage of the hands-on care would have been delivered by Registered, Enrolled nurses or students, in contrast today much of the ‘nursing care’ is done by HCAs. Continuing professional development beyond initial registration is a further concern, as funding and availability vary widely, leaving many nurses frustrated in developing their career. There is still much greater emphasis on hospital based training which is not a true reflection of the shift in
healthcare. More consideration needs to be given to General Practice placements where students can gain a much broader understanding of health.
The role of the leader at local and national level
We live in a 24 hour 365 day culture, where expectations are higher and there is a greater emphasis on individual rights. Many of the criticisms directed at nursing reflect other changes in society. Patient turnover is faster, patients in hospital are sicker and more tests and treatments are available, alongside which patient expectations are higher and complaints and litigation are more common. Record keeping is by necessity an important part of patient care, but is often perceived by patients as ‘nurses sitting at desks’. Perhaps time spent teaching record keeping and better use of technology could make the task more accurate and efficient. Leaders at local level need to spend time on the ground to ensure they really understand the workforce, training and resource issues. They need to be visible and approachable so staff feel valued and supported. They also need to be able to fight on behalf of the nurses to ensure that work environments are properly resourced, protected training time is facilitated and safe staff levels are maintained. High levels of stress and sickness are known to lead to demoralised and potentially unsafe practice. Clinical leaders in whatever area need to be encouraged and facilitated to influence decision making outside their own clinical area. An example of this is the work of the RCGP General Practice Foundation who are setting standards and competencies for Practice Nursing and seeking to establish sustainable national foundation training for all nurses seeking to work in General Practice.
Role of Boards and regulators in measuring and managing improvements in quality
There is a need for governance measures to be in place to ensure that care is of a high standard as there will always be a conflict between cost and quality. Board level decisions need to be based on a good understanding of how care can best be delivered and measured so on the ground clinicians need to be informing high level decision makers. Great care needs to be taken to measure the right things and not just numbers; otherwise real improvements will not be demonstrated. An experienced pair of nursing eyes and ears can identify good and bad care in a way that complex audits or form filling may fail to achieve. Regulation is a necessary part of ensuring quality. Human nature dictates that we are more likely to stick to the rules if there are some to follow. Employers are much less likely to fund training staff to a certain standard if there is no requirement by a regulator to do so. External inspections by the CQC and other external bodies do make health organisations get their house in order. We have much to learn from our medical colleagues who now have a robust revalidation process to ensure that doctors can demonstrate ongoing competence in their speciality. Nursing needs to provide similar safeguards to ensure nurses maintain their skills. There are two groups (Advanced Nurse Practitioners and Health Care Assistants) who would benefit from better regulation to protect patients. HCA’s need this because they are delivering so much of the ‘nursing care’ and therefore must be adequately trained. ANPs because they pose a risk to patients because of the level at which they work, assessing diagnosing, prescribing and referring.
What can be done?
We are currently in a vicious circle. Past decisions about recruitment, training, resourcing and supervision have led to a widespread deterioration in the respect that nurses show to patients and vice versa. It is down to leaders in nursing today to be better role models and close the gaps
which have opened up in recruitment, training and management. Regulators need to rise to the challenge of ensuring quality and protecting the public. Finally, if compassion, communication and care were restored to the heart of nursing many of these issues could be resolved.