Monday, 4 January 2010

Should they Bring back Enrolled 'ward trained 'Nurses?


Nope.  I don't think so. 

 I believe that under such a system we would still have "team nursing".  Team nursing sucks.  It worked great back in the 70's but there is too much information to keep track of as well as disorganised  chaos now all thanks to medicine advancing and higher costs  

Team nursing came about during WW2.  It is the system in which our older, traditional trained nurses are familiar.  It works properly only when ward structure is meticulous and well organised.  I happen to believe in primary nursing.  This doesn't mean that I am not a team player however.  I will drop everything to help a colleague who has a patient in trouble, or is in trouble herself.

Have you ever wondered why you have noticed loads of staff in nursing uniforms hanging about when you visit your mum in hospital...yet no one seems to have a clue about what is going on....no one can give you any answers..... none of the patients are recieving their drugs on time.......and the only person who does supposedly know what is happening  (mum's RN) didn't realise that your mum just had a dangerously low blood pressure reading 10 minutes ago?  Does any of this sound familiar?

This all happens because Registered Nurses are running between too many patients, with less qualified staff to assist them.  It is a system that doesn't work.    Some people are saying that we should bring back enrolled nurses to help the RN's. EN's are an improvement over HCA's but a cost cutting NHS will just use them incorrectly, as they do with the HCA's.

I don't want enrolled nurses ( EN's  as they were known) around unless the hospital is going to add them in addition to safe registered nurse staffing ratios .

They won't do that, they will only use them instead of registered nurses.  Before you accuse me of knocking EN's please read on.

People generally seem to think that degree educated registered nurses don't do much in the way of ward training and that we need to bring back ward trained nurses (EN's) to improve care.  That is a motherload of crap.  We need to do lots of things to improve care, but not that.

Where do I begin.

The degree students have to do nearly 3000 hours of ward time/placements to qualify. The degree students are working shifts on the ward all the time.

During the weeks and weeks of their placements they are working full time shifts on the ward.

They are supposed to be supernumery but they ARE NOT actually supernumerary.

They are thrown right in at the deep end, doing all kinds of basic care. Take it from someone who is currently practicing as a staff nurse and who works with students. This is indeed how it is in 2010.........   current nursing students spend thousands upon thousands of hours mucking in on the ward.

The  idea of bringing back traditional trained nurses (or EN's) as well as degree nurses is a good idea on paper but it is a total fail in reality.

The reason for this is that TEAM NURSING DOES NOT WORK anymore.

Team nursing is what you are actually pushing by arguing that they should bring back EN's. Team nursing is when you have an RN's, EN's and auxillaries all caring for a large group of patients. It doesn't work. It fails because the RN has to be on top of everything that is going on for 30 people and no matter how many EN's or care assistants she has, the RN is overwhelmed.

Team nursing means the right hand does not know what the left hand is doing.

What we need is for a degree trained RN doing everything and having a small enough patient load to do EVERY aspect of her patients care herself. This is cost effective and it is the only thing that works.   Giver her a care assistant to be used only in case she runs intro trouble but my god, leave basic care to the RN's primarily.

I don't want an EN or an auxillary sharing my patient load because I want to do everything myself for all the patients. The majority of RN's I talk to agree. Primary nursing is the only way to stay completely on top of everything that is going on. 

If you throw more patients at me along with EN's and care assistants instead of Registered Nurses then fuck up after fuck up after fuck up occurs.

Yes, nurses having more technology, drugs, and medical stuff to do these days. We do indeed and staff nurses get held responisble for any screw ups with these things.

 But in order to do those high tech things well, I also need to be doing basic care myself. Otherwise I am not seeing the whole picture. And neither are the EN's or the care assistants. When there isn't anyone at all seeing the big picture, all hell breaks loose.

If I am delegating the basics to an EN or HCA then that means that I am probably the only RN on shift and I am overwhelmed doing drugs for the entire ward , doctor orders and rounds, relative enquiries, and fire fighting  for all 30 beds. This is overwhelming even if I have 100 care assistants/EN's to help with the basics.  

Just the sheer number of relative enquires either in person or by phone is overwhelming when you are an RN with  only 10 patients. The questions these people ask are usually only answerable by the RN.  If I have 10 patients I have 10 families on back and I can barely get any patient care done.  I can barely ge away from their phone calls and interruotions long enough to actually see any of my patients.  There are just so many interruptions. Constantly.

Under the plan to bring back EN's, the RN will be the lone RN carrying all the the things that the EN's and HCA's cannot do . She will be overwhelmed. Meanwhile the EN's and HCA's will be merrily making beds and gossiping without a care in the world.  Whenever a relative makes an inquiry or a patient becomes acutely unwell, the EN' s and HCA's will just dump that onto the RN and happily go on their jolly way making beds.  And the RN will be managing 5 critically ill patients that she cannot even get to because she has the relatives of her other 25 patients on her back.

I want 4 acute patients or 6 non acute patients maximum and I want a charge nurse without a patient load on shift to back me up and organise the ward . I want to do EVERYTHING, EVERY nursing intervention for my patients myself. Myself. I cannot do this with 30 patients no matter how many EN's or HCA's you throw my way. Even if I have hundreds of EN's and HCA's with me doing the basics I am still going to have too much information to process, too many interuptions and total cognitive overload.

A growing body of evidence is showing that a well educated RN doing everything for a small number of patients  is the only safe, effective, and cost effective way of doing things.  The WW2 ward structure planning is still in effect now, just with less qualified staff.

What I am trying to say is this: If you throw  EN's and HCAs at me instead of Registered Nurses then I have to keep track of everything for the entire ward as the lone RN. No can do.  Not these days.  It is impossible. 

And that is the case if I am sharing my 30 bed ward  with 1 EN or  100 EN's in a single day.

What they are doing right now in hospitals  is essentially team nursing. 

What we have now is the hospital managers saying this:  "It's okay to stick one RN with 20 patients because we are throwing care assistants at her.  She can  medicate, all 20 patients,  keep track of information for 20 patients, get interrupted to take questions from the families of 20 people with nothing in place to control the number if interruptions she is getting  etc as long as she has a few less qualified staff around to make her beds and wash her patients.  Do you really think that it would be any different if they brought EN's back? 

They would probably have one EN in charge of a 40 bed ward with no RN and a few care assistants to help.  That is how NHS management does things, the cheap fuckers.  Not only do they currently have a world war 2 era ward structure in place on the wards ......  but they have it with less qualified staff at a time when patients are sicker and the stakes are higher.  Even in the last ten years, patient acuity and costs have SKYROCKETED.  Nurses in 2010 are dealing with sicker patients and have to do more for them in a shorter amount of time, with less qualified staff.  Fallen angels my ass.  I actually think that nurses today are much nicer than their yesteryear counterparts.  The older nurses just had better ratios, resources, back up, and smaller workloads.

And this kind world war two era mentality  by managment and dinosaurs is why things are so shit.  The idea of bringing back EN's is a good one on paper but not actually implementable because team nursing is outdated. Let's move away from it entirely.  Staff the wards with RN's, and when RN's have safe ratios then you can add in the assistants to assist with care rather than taking over care  when they are not qualified to do so.

33 comments:

Anonymous said...

A family member was in hospital recently, big crisis, high dependency unit, heart problems - anyway we asked at the nurses station if we could phone and ask how she was (limited visiting hours) - they said yes, of course, phone any time. We would not have realised it might be a nuisance from anything they said. (Also noticed people doing drug rounds on the main ward had aprons saying 'DRUG ROUND - DO NOT DISTURB' on, in big letters).

Nurse Anne said...

That sounds like a good hospital.

We don't have those aprons anymore because the public just ignored them.

From what I know about high dependency they have less beds, and more registered nurses.

Each nurse on high dependency should only have a couple of patients. They will also have the back up of a ward clerk to answer the phone. That makes it easy to communicate with the families.

My ward is general medicine. That is a whole different world from high dependency.

We are more like 2 nurses to 25 or 30 beds. No ward clerk to answer a phone which rings constantly.

Sometimes multiple members of the same family ring all day long and many of our patients are not critical.

I can easily spend 40 minutes out of every hour answering phone calls from relatives with questions like "is mother wearing a hospital gown or one of her own?" and "when will she be discharged". There is really no way to answer the discharge one. There is no set time frame for anything in general medicine (there is in surgery however).

I will get a call like the ones I just described from Mr. Smith's neice, then the same question from Mr. Smiths brother in another phone call 10 minutes later. 20 minutes after that Mr. Smith's daughter will phone and ask the same questions. They don't speak to eachother you see. Then when Mr. Smith's wife comes in during visitors she asks the same questions again.

I get this constantly from the families of all 30 of the patients on my ward. With no let up. It would be different if I had only 3 patients in high dependency.

IF we cannot come to the phone right away, or if we ask them to designate one family member as the caller who shall them disseminate info to the rest of the family they fly into a rage.


If I have a critically ill patient because there are no beds in high dependency I also tell the families to ring anytime.

Nurse Anne said...

I should add that in that situation I tell the next of kin only to ring anytime. The next of kin is the person listed on the hospital admissions form as designated next of kin. I am not legally allowed to give any info out to anyone else.

But the next of kin never calls and everyone else in the family does. Repeatedly.

GrumpyRN said...

As an ex Enrolled Nurse I am well aware of what the role entailed and I don’t think you appreciate what the EN actually did Anne.

You talk of "delegating the basics" to an EN, this did not happen. An EN is, or should be, a valuable member of your team who is a registered nurse in their own right and any delegation is done in the same way that the Charge Nurse/Senior Charge Nurse delegates to you. As an EN I looked after my own patients including the sick ones. I could and would do a drug round for the whole ward – in fairness doctors did IV’s in those days but I still had to know and understand drugs. I would on occasion be the nurse in charge of a ward, I mean completely in charge as the only trained nurse there working with a couple of students and an HCA. As part of my training I learned the basics at the same time as the RN students – on the wards at the bedside. EN’s are trained to be ‘bedside’, ‘hands on’ nurses NOT glorified HCA’s. We were trained to understand illness and the disease process and also to interact with our patients and with their relatives – I was well able to talk to patients relatives either on the phone or face to face. I also on many occasions did the ward round with the consultant. The difference between me and an RN? I did not do as much depth as the RN students and I was not prepared for management. I still had to pass exams and I gained a registerable qualification which I will still on occasion write down.

Now having said all that, would I like them back? To be honest I’m not sure, it will not be a cheap option as you think as EN’s are registered as second level nurses and as they are registered they automatically become Band 5 nurses. I recently corresponded with a Band 6 Enrolled nurse. Where EN’s do come into their own is in giving people who only wish to get into nursing a chance to do it with training, registration and accountability without having to go to university.

It strikes me that if the plan as you are stating it is to make EN’s super HCA’s this will definitely not work. However, if EN’s have a similar type of role to what they used to then yes there could be some merit in it BUT it will not beat having proper degree trained nurses on the wards especially as they still have to be paid the same as a degree trained nurse.

Nurse Anne said...

"BUT it will not beat having proper degree trained nurses on the wards especially as they still have to be paid the same as a degree trained nurse."

and that is why it will fail. They will leave an EN in charge of a ward with nothing but 16 year old untrained kids to help.

I am familiar with LPN's and EN's and they were for the most part very knowledgable and secure as nurses. However I don't want an EN doing all my drugs for me because I will then miss a critical part of my patient's picture. And I don't want EN's used as an excuse to stop RN's from being hired as ward nurses.

Nurse Anne said...

My hospital made all the EN's get their RN, otherwise they were made into HCA's.

GrumpyRN said...

I take your point Anne but if they are not going to staff the wards properly it does not matter what you do you will fail.

"I will then miss a critical part of my patient's picture" - What you have to remember in this is that they would be the EN's patients not yours, they are registered nurses too. Would you go behind another RN checking their work? I would have been mightily pissed off if a staff nurse had come behind me to make sure the patients were all right without good reason. EN's were trained nurses who did the same job as a staff nurse but were junior to the staff nurse - yes. yes, I know that things have changed and patients are sicker and there are more technical things requiring doing but for good basic care of a patient you cannot beat a good experienced Enrolled Nurse.

I sound as if I am advocating the return of the EN, I am not I am trying to point out in my illiterate manner that EN's were not just trained HCA's.

I'm not convinced that your hospital were allowed to force EN's to change as I am fairly sure that is against RCN and the NMC rules. Obviously if they did it they did it. My hospital still has one or two EN's running about and I have already told you about the Band 6 EN - she had been in that post for 15 months and was actually looking for advice on how to become a level 1 nurse without going to university full time. You can find her letter here and my answer. Look for katogirl.
http://careers.guardian.co.uk/forums?plckForumPage=ForumDiscussion&plckDiscussionId=Cat%3afbe1954f-19a7-4006-82a3-08b5319f4c1dForum%3a7296f258-6ce7-4743-b359-795e7661e245Discussion%3a732ab509-9f55-49ef-a7a7-7b594df567ae&plckCurrentPage=0

Nurse Anne said...
This comment has been removed by the author.
Nurse Anne said...

Oh they forced them all right.Or so I was told by the EN's. Maybe they just said that though I don't know. I thought it was the NMC doing it.

I have only ever seen LPN's and EN's work under the direction of a nurse mostly. For example lets take ward with a 12 patient zone staffed by an LPN and an RN. 6 patients belonged to the RN and 6 patients to the LPN (EN). The RN had to do the assessments, charting, IV drugs and doc calling on the LPN's 6 patients in addition to her own.

Did EN's do IV's and care planning?

If so, I want one. I'd rather die than mix up another batch of BenPen2.4 grams. What a PITA.

You are right though, anything we do will fail right now.

GrumpyRN said...

When I was an EN we were exactly the same as the Staff Nurses except they were always going to be in charge of the ward. I wrote my own documentation and called a doctor if I felt it was necessary.
If there was no RGN on duty then I was boss.
In the 80's nurses did not do IV's except in places like CCU, ICU Renal Dyalisis etc. slowly over the 90's we somehow decided this was our job so less time to do the drug round. If the EN was free at drug round time s/he did it with a student - and was expected to teach the student while doing this. After I converted to RGN they stopped EN's doing the drugs unless they had done a competency test, but this was not that difficult and most of them just carried on as before.

So yes, used properly a good EN can be worth their weight in gold.

Anonymous said...

The EN sounds like the equivalent of our diploma nurses here. I an RN who had gone the diploma track before it was phased out. She had years of experience on her and taught me a lot. She had what I call "horse sense", meaning she had good judgment. I work with a LPN who is one of the best nurses on our unit. She does not do IV pushes or piggybacks or hang blood. She also cannot do admission assessments. It would be a nightmare having to be the only RN on my unit (it's happened), but this LPN is really good.They are a good adjunct to the RN staff, if you can utilize what they are trained to do and can legally do appropriately - appropriately being the operative word.

Nurse Anne said...

EN's are LPN's.

The diploma nurses in the USA are RN's and have to take a lot of university courses to graduate. They do university level microbiology, anatomy, pharmacology, English,maths etc.

I know because I did my diploma first, at one of the last diploma schools. They were in the process of transitioning to a BSN program so after qualifying I didn't have to take very much more to get a BSN.

Nurse Anne said...

We also had to keep top grades in science and math and all of our other university courses that were providided by the university or we got kicked out of nursing school.

It was a half and half thing. Our nursing courses and placements were done via the school of nursing but our university courses were done via the university that was liased with the old school of nursing. You could either get all the university stuff out of the way before attending the diploma program or do it simultaneously.

It was good but gone now.

Nurse Anne said...

The reason I choose that school was because I already had years of uni under my belt majoring in something else and because they had a 100% pass rate for the state nursing board exams among their students. Even if I had not done the BSN afterward I still would have been able to do every single thing and ASN or BSN could.

The state I was in really screwed the LPN's I'll never forget what they did to them. Glad I went straight for the RN.

capgrass said...

keep up your posting grumpy. personally i reckon you are Charlie Fairhead. in nursing EXPERIENCE is EVEYRTHING...........EN`s were invaluable and many of the ward managers and sisters you see on the wards now, and the "lifers" in A/E ICU and theaters........were once ENs who got the RGNs, their children, their spouces and their nurse tutors to help them write their essays and thus past their "conversion courses". Also I am so Glad Grumpy is a pervy old male nurse. He probably brings a delicous black humour into the most tragic of situations that we encounter in hospital. I always love the male nurse who acts as a balast against the dreadful atmosphere of female self sacrifice...........which comes from the likes of Anne, Nellie, Dyno nurse, student nurse and a whole lot of other worthies.

Nurse Anne said...

Capgrass,

The NHS has depended on that angel female self sacrifice shit in order to keep costs down.

The public better hope and pray that nurses never become anything other than bitter self sacrificing martyrs.

Because if we do leave all that behind and they have to start paying us for all the hours we work, treating us as something other than a battered wife who takes the blame and a beating for everything under the sun, giving us the resources we need to do our jobs other than the "make do without or take the blame for failure-you ARE an ANGEL aren't you" culture that we have now..................the nhs would shut down. They balance the books on the backs of frontline nurses.

Anonymous said...

We do a kind of team nursing on the early shift. We have 4 staff nurses and 2 HCA's (if we aren't short!) and split the ward in half, so 2 staff nurses and 1 HCA work together. ! staff nurse the most senior of the 2 is in charge of that side and does the drug round, the other helps the HCA with the basic care and the monitoring (hourly BM, hourly Obs etc). Dressings tend to be done by the junior RN, ward round by the senior, but there is alot of overlap and often if there isn't great communication we don't know what the other is doing. There will be a big fail I'm sure. I have suggested that we split the half again so take a smaller amount of patients each, but that was rubbished at the staff meeting.

Oh and we are getting those aprons apparently for drug rounds, we shall see if they make any difference at all.

Nurse Anne said...

That is how we used to be staffed and do things anonymous.

Now we often end up with 2 staff nurses and two care assistants for the early. A staff nurse and care assistant on each side.

Occasionally we get 3 or 4 staff nurses and find that the best way to do things is primary nursing, which was rubbished at your meeting as opposed to team nursing.

Anonymous said...

Is it just me or anyone else wish Claire Rayner would explode courtesy of the whole volume of hot air inside her. Just had a quick browse seems she started nursing sometime after the war and left when she had her first child. Of course, it was better then, there was no advanced imaging, no ITU/HDU, no commitment to finding the best practice by conducting solid research, about two antibiotics and chemotherapy drugs and if you had an MI medical HO would give you some Aspirin and a pat on the head. Of course you all had lovely tidy hair then. http://www.dailymail.co.uk/health/article-561164/Why-gossiping-nurses-symptom-NHS-crisis.html

Nurse Anne said...

Oh Claire Raynor is nuts.

Did you see all the comments from that article accusing the nurses of giving the drugs to healthcare assistants to administer because they "don't want to do it themselves".

Ever nurse knows that hca's cannot give meds without risking loss of registration. Every nurse knows that you cannot leave drugs unattended. But every nurse (on my ward at least) is left without a choice much of the time because there is so much going on that stops you in your tracks while you are right in the middle of giving 20 tablets to a confused elderly lady. Gee I can stay here until she takes every tablet or I can ask the HCA to sit here with her for 45 minutes and go running to the person who fell and broke their hip and is laying on the floor bleeding.

Anonymous said...

Your post above, Anne, reminds me of a day when I was newly qualified, doing a drug round for half the ward, and sat with a muddled patient who had about 10 tablets to take. Bless him, he was taking about 5 minutes per tablet.

I was absolutely horrified at my inner thoughts of "bloody hell, pleeeease hurry up! For Gods sake, Pleeeeaase!" I was absolutely frantic inside beacuse I knew that too much time sat here, would mean that the 0800 drug round would not finish until 1200 gone, then the 1200 round would be due - totally overdosing some patients.

Who would do all the assessments of patients conditions while i'm on an never-ending drug round, who will do the all the IVs, the dressings, the peg feeds, doctors rounds, new admissions, discharges etc etc etc..

It was a eye-opener for me, realising that, in 14 years as a HCA before qualiying, I had NEVER felt frustration towards a patient situation like this. And this was just the beginning of a career of total frustration.

If, as Raynor says, nurses are hard and callous these days, then its nursing and the NHS that has made them that way. She hasn't got a bloody clue!

Nurse Anne said...

I hear you. 100%.

And you are expected to sit with and medicate 20 such people in an hour. An hour. While dealing with a 100 other things and constant interruptions.

And if you don't you have to listen to this: "if only the nurses had BOTHERED to try and get his tablets into him" AND "if only the nurse had BOTHERED to try to get his tablets into him"

And if you collar an hca to help the patient get his tablets down him while you stand at the bed of the next guy and try to get his tablets down him while watching the hca get the tablets into the first person you are accused of dumping your job onto the hca and not taking your medication duties seriously..

it is a no win situation.

If you stayed with each and every advanced dementia patient in a futile effort to get their tablets into them you will miss the boat on so many other things that you will get sacked. Very quickly. And then you will get accused of "not bothering" with a thousand other things. And no one is going to pat you on the back for trying with the dementia patients medication (and maybe being successful) which lead to the omission of those thousand other things.

I am going to be honest here. If I did the drug round properly it would take me 8 hours just to give the 8AM drugs. That means that I would not even be getting to or seeing the other half of my patients with their 8AM drugs until well past noon. And that would be to the exclusion of everything else that is going on.

Nurse Anne said...

and that is with me knowing about 101 different tricks to get someone with advanced dementia to take their medication.

Alexis said...

Things have gone even further since you left the US, Anne--I know that where I am from there are very few LPNs left in hospitals, and I don't think it's much different where I am now. LPNs are relegated to duty nursing and nursing homes. Some of the big hospitals are only hiring BSNs.

Nurse Anne said...

They were treating the LPN's like dog poo even during my years there.

The state board of nursing had stopped LPN's from being able to call the doctor or take doctors orders. Full stop.

That lead to this:

Picture a newly licensed 23 year old RN who had been an RN for 5 months having to call the doctor for an LPN's patient.

The LPN had been an LPN for 35 years, had noticed that her patient was unwell and needed the RN to call the doctor for her as per NEW state board rules.

That RN was me. Mortifying. Mortifying. Mortifying. She forgot more than I ever knew about nursing.

Toby said...

Good point well made on the logistical side and coal face/pratical side, however given the fact that this country is now a monetary black hole/cess pit after 12 years of this Labour government and that we are now on course for years of pain just to get back to sane debt levels .. well, not even firing/burying all the managers will get the costs down to employ more RNs to a 4-1 ratio.

I'd love to see someone work out the cost of this and how it could be realisicly achieved.

toby said...

ps: my dad has just got out a high dependency ward after a lung op.

the staff there were very good and there seemed to be enough of them in the ward, all med rounds ok and everytime I went in there was no rushing or problems.

I dread the day I ever have to be subjected to a NHS general crit ward

Nurse Anne said...

Our high dependency units function okay at my hospital. Heard some bad things about others. I would not be the least bit scared to end up on a critical care unit at my hospital either.

Maybe you'll get lucky and end up on a decent medical ward. I believe they are out there. I think that we do a decent job half the time with what we are given to work with on my unit. But the floor below us OH MY GOD!! I would refuse to let a loved when get admitted there purely based on the staffing levels.

American Attorneys said...

This all happens because Registered Nurses are running between too many patients, with less qualified staff to assist them. It is a system that doesn't work.

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Anonymous said...

I qualified in 1984 as an Enrolled Nurse. Within 6 months of qualifying and working on a Thoracic Surgery ward with an attached HDU, I had been trained up to give IV´s and also I was left in charge on the night rotations.