Sunday, 21 February 2010

The Nursing Students.



There seems to be a lot of myths about modern nursing students here in blog land.  I see these same kinds of lies and distortions repeated in newspapers and conversation everywhere.  It is like some kind of weird groupthink situation.  People jump on the bandwagon without having any idea about what they are talking about.  What do you know about what educational requirements a nurse requires to do her job safely?  What do you know about what he/she studies in nursing school?  Unless you have experienced it firsthand, the answer is that you know fuck all nothing.

Myth number 1:  Nurses do not need to be university educated.

Well, as of right now anyone who actually qualifies as a nurse is university educated.  If you want to be a nurse you either need to do 3 years on a diploma or 3 years on a degree.  The difference between the degree and the diploma is one essay. It is tougher than your average 3 year degree at university and it needs to be.  Many of our nursing students are older and are taking nursing on as a second career.  They have previous degrees.  I have a previous degree and I agree with the majority that nursing school is harder, more work, more to learn, and more pressure. It may not be law school or medical school but it makes degrees in things like english, social care, history and teaching look like a walk in the park. 

 Very few of these graduates are getting jobs on the wards because managment thinks that cheapest is best.  They are hiring untrained kids off of the streets instead.  These people cannot do the job of a nurse but are staffing the wards instead of nurses.  This means that many aspects of patient care gets left undone because the untrained kids are incapable. 

  Bring the Enrolled Nurses back and you will have one EN on a shift for 30 patients, with the rest of the staff being untrained, uninterested, and unregistered kids.  If you take nurse training out of the university and train RN's under the old fashioned method the same thing will happen.  Anyone who has any training needs to get paid more than minimum wage and is legally bound to speak out about problems.  Management does not want anyone like this staffing the wards.  They want untrained cheap labour. If you even have a smidge of training they don't  really want you.

Let us not forget that as the education level of your bedside RN increases, your risk of dying and complications decreases.   If that RN is given too many other patients, with either no one or only poorly educated untrained kids to assist her, your chances of survival plummet..  You want stats?  Look to the right hand column on this blog's home page.

Myth 2: They pulled nursing students off the wards to go to university.

Bullshit.  All nursing students have to do at least 2300 hours working on the wards or they do not graduate. Fullstop.  Good essays and exam grades will not save you if you haven't put in your time working on the wards. The university education of nursing students is in addition to ward trained vocational training.  The ward based and nurse theory training  occurs simultaneously with their classes at university.  My nursing student worked three 14 hour shifts and a 12 hour night shift last week on the wards. And they have their regular school work as well.  The nursing students in the 1970's could function as a nurse because worries about liability did not stop them from giving drugs or caring for a group of patients unsupervised.  A student could take half the ward as a primary nurse back then and any mistakes were swept under the carpet.  These days, a student nurse cannot do anything without being under the direct supervision of the RN.  This means that they cannot just go off and take on a group of patients while I cover the other half of the ward.  It is down to liability.  If something happened to a patient, and the barristers found out that a nursing student involved was caring for patients in the way that a nursing student is the 1970's was, all hell would break loose.  The hospital would lose a very big lawsuit.

Myth 3:  Nursing students  sit at the desk doing paperwork and protocols.

I have two degrees, one in nursing and one a bit liberal artsey. I have been a university educated bedside nurse since the early 90's. I have never had anything to do with writing protocols, nor I have seen protocols.  So why would a nursing student?   The nursing students are taking care of patient needs that their nurse mentor cannot get to because of high ratios.  They bust their arses doing so but often have no one to show them properly how to do things.  We show them the very basic basic paperwork that needs to be written to get the patients the things that they need and documentation that is required for the lawyers.  And we don't even get that stuff done well.  The students come to the ward with packets of paperwork for their nurse mentor to fill in and sign off to prove that they know their stuff.  

There is no time to do this whilst on duty as the only RN for a large number of patients.  I have found that the only way to get through the initial interview, the midplacement interview, and the final interview is to come in unpaid on my days off and meet with and assess my student.  Then we sit down and check off whether or not she can insert a catheter, dress a wound, etc etc. The hospital and the university know that the nurse mentors are in no position to mentor properly but both institutions cry "no money, no money" when ideas such as  official clinical mentors in addition to ward staff are mentioned.  My nursing school  (non UK) had official clinical mentors in addition to ward staff to work with the students.  These clinical mentors came to the wards with us from univeristy. They worked for the univeristy.  But they were also experienced staff nurses at the hospital we were training in. Believe me, this is the way to go.

I love mentoring so I don't mind even coming in on my days off unpaid for the odd hour or two. And it is a good thing I don't mind because you don't get a choice about whether or not you mentor if you work as an RN in an NHS hospital.  Mentoring is required to get your yearly pay increments.  It is a requirement to go through the gateway. So if you don't do it you don't get your normal pay rise, and that is all the pay you get for it.  I am getting a new student tomorrow to follow me for the next few months.  His first shift with me is tomorrow.  He had his first shift on the ward on Friday.  That was my day off so I ran into work for an hour to meet with him and plan his learning objectives etc and do the initial interview.  We will have no time for that shit tomorrow when he is following me as I will be the primary nurse for many patients. 

Myth 4:  Nursing students are supernumery.

Everytime I hear that line I laugh and laugh and laugh.  Nursing students are still very much unpaid labour used to staff the wards. If we have students on the ward, our manages use that as an excuse to get rid of care assistants and not book any agency carers for the shift.  I have often been left with a large number of very ill patients and only a nursing student working with me. Most of these students jump right in, get their hands dirty and do the best that they can.  It is chaotic.  It is disorganised.  It is a terrible learning environment for them.  They learn nothing but how to take enough short cuts to ensure that they can answer 150 call bells a minute. I will try and show a first year how to do a bed bath and what kind of assessments they need to be making when doing a bedbath, and how to tie all that in with what the medics are doing for the patients.  I will get 30 seconds into something like this before I am called away and have to move onto something else.  The interruptions are relentless, constant and never ending when you are on a ward nurse. The student ends up just learning as they go without their mentor teaching them the right way.

Recently I blogged about taking a critically ill patient who should have gone to ITU (no beds).  The nurses on his short stay surgical unit couldn't handle him so the site manager turfed him to my ward.  He was in no state for any kind of transfer.  He needed one to one constant care.  I thought my student was about to see her first crash and  quizzed her about what she needed to do in that situation.  This situation left my nursing student caring for my other 14 patients alone.  She could not medicate them, or do IV's or many other things because it must be supervised for legal reasons (i.e. trust doesn't want to get sued) so those things just got missed.  She did what she could do: the vital signs, the basic care, catheter care, fluid balance charts, call bell answering, etc.  She ran her ass off without a break to stay on top of all that for all those people.


DinoNurse has seen the same things at her hospital:

Why exactly should the NHS be left to sort out social services, housing, bills, pension payments et etc? Why should acute beds be blocked whilst relatives drag their heels over picking where to bundle granny off to? Acute wards then get turned into halfway houses and management types assume that they can scrap the RNs and staff these wards with HCAs...never mind that such a mix of acutely ill and frail, uber dependent patients is a recipe for starvation, infections and disaster. Just last week I transferred an HDU patient to a medical ward staffed by 2 RNs and a student. No HCAs or APs. Place looked like Beruit. After handing over BOTH RNs asked when ICU would be recruiting agin. Out of guilt I phoned the unit and stayed to help do the IVs so that they could try and feed some of the patients. Then I helped the student to bedbath the half a dozen patients that were still in wet beds. Enter floor manager just as I am wheeling the overladen skip to the sluice to rebag it..."oh sister, why aren't you in the ICU?" Gave him one of my famous Lisa Simpson stares..." agency were booked but didn't show" he stammered...then turned on his heel and RAN back to his office. I swung by on my way back to the ICU and informed him of the IR1 that would soon be landing on HIS desk for a change.

Myth 5:  Modern Nursing students are to posh to wash and to clever to care:

It strikes me as hilarious because I haven't seen any evidence of this in over a decade of nursing and over 5 years of mentoring. If anything, the nursing students are so bullied and harassed by the health care assistants(who think that the students exist to ease their workload) that they do not learn enough about professional nursing before they graduate. Nursing students are knee deep in shit cleaning and basic care for the entirety of their training. This is a component of proper professional nursing but it is not everything, not by a long shot. When they qualify and are thrown onto the wards as the sole RN for a large number of patients they struggle as a result of spending more time with the care assistants than the nurses whilst they trained.



The nursing student has to be strong. He is a year from graduating and has spent his placements working for the care assistants while his overburdened mentor struggles to do her job. Now he is scared. In no time he will qualify and he doesn't feel that he has spent enough time on the aspects of care that only a registered nurse can accomplish. He has spent all of his placements bedbathing and working for the care assistants doing basic care. He decides to stand his ground. He tells the care assistants that he will be doing the drugs and the assessments, the admissions and the discharge with the nurse today. He is going to stick to the nurse like glue and learn how to keep track of and process the vast oceans of information that a nurse needs to stay on top of for all these patients. He is going to learn the system he has to be able to manipulate in order to do his job. He is going to handover to the oncoming shift. This is a crucial skill. He needs to be on top of everything to avoid disaster and he needs to learn how to do it. In no time he will have a nursing license and he will have to do it all with no support. He realises this, his mentor supports him and he tells the care assistants that he is going to stick with the nurse this week rather than helping them do all those turns and feeding as usual.


The health care assistants do not understand why he has taken this stance. They think he is disrespecting them. They think that he is on his high horse, uppity and snobby and imagining himself better than them. They think he is lazy and that his university education is causing him to believe that he is above the basic care that he has been doing all these years of training. They get angry. They resent not having his help doing all that physical labour. He is an extra set of hands that they need. Then they tell anyone who will listen that the new nursing students think that they are above basic care.


Many nursing students are not strong enough to say enough is enough to the care assistants.  There is so much pressure on students to just be that extra set of hands all the time. Then they qualify and all hell breaks loose. I have seen more than one new RN sacked for errors. The reasons for these errors is because their placements consisted of working for the care assistants rather than learning how to be a nurse. When they qualified, they were unable to make the transition over.


That is of course, assuming that they can actually find a job when they qualify.  If they do manage to get a job on the wards they will run away screaming a year later.  The sheer volume of patients they will be expected to take care of at once without any support are absolutely brutal and it sucks the life out of you.  This  in conjuction with general working conditions on the wards achieve a level of abuse that most people cannot take and remain sane, well balanced and articulate.  We do lose far to many of them before that first year is up. 


The problems on the general wards these days are a result of a lack of trained, experienced, educated and registered staff. The vast majority of the staff on the wards should be well educated and registered. This is cost effective and it stops patients from dying. The reality is that the vast majority of staff on the wards are untrained, uneducated novices doing a learn on the job approach. They are apprentices, care assistants and nursing students. We don't need to go back to old fashioned vocational nurse training in order to get cheap and free labour by non academic but caring people. We have that now. We have far too much of it.

I'll never understand why people blame university educated nurses and nursing students for the mess we are in. You need to be looking at the people who control the ward budgets...and those people are not nurses.  They are not ward sisters or matrons or nurse managers either.

We need more proper well educated RN's staffing the wards full stop.



194 comments:

NHS Nursing Student said...

Amazing blog! I love it. Great 6am reading material. Everything I've been covering in my blog in some way or another over the last few months too and you've summed it up, you're doing me and other students proud Anne! Keep mentoring, you're fucking brilliant and you know the old saying, it will all come out in the wash!

Nurse Anne said...

To be honest I don't always feel like a good mentor. I feel like my students are getting left to sink or swim to much and that I never have enough time to teach and assess. I would like a full time job working with students I think. It's really hard to mentor well when you have a 12-14 patient load.

Matt said...

I was on placement the once, the ward had 4 bays. All the bays but one were allocated an RN and a HCA, apart from the one I was in. It was just me and the RN. Along with 3 side rooms. This was an elderly care ward. I decided I wanted to spend time with the RN learning the meds as I was sick of being used as an extra HCA. The washes were not finished by 11 am and we had to ask for help, partly because there was no HCA to start the washes whilst the drugs were being done. The HCA that was asked to help went running to matron to say that we were not pulling our weight and that the student (they seem to forget I have a name) was not doing basic care.

I am perfectly capable of delivering personal care, and do not mind doing it, but if I don't know how to do the tasks an RN has to do in a years time, I'm fucked and might aswell burn my registration fee.

Nurse Anne said...

Matt, I have seen it 100x myself. These HCA's are relentless. I wish my major stressor in life was trying to do all the bed baths by myself. And I was an HCA once so I have done it.

They did it to a new hire RN we took on last year.

She had qualified as a nurse years and years ago and then started a family. Her child was severely disabled and she took a few years off of work. Then she went very part time in a nursing home for a few years. When her son died, she sought full time work in hospital.

This very nice woman had not nursed in acute care for 8 years. Her very first day on the job was nerve wracking for her. She was supernumery and her nurse mentor was showing her the ropes with the drugs and IV's. We know how it goes. This out of practice nurse would only get a week on orientation before she was left in charge of 15 medical patients on the ward. She need to learn the RN ropes and learn them quickly. Realisticaly it would take an out of practice RN a few months at least to get up to speed. But we knew that she would only get a week.

We knew she knew how to bedbath and do basic care but she was way out of practice with the RN stuff.

On her very first day the hca's were having a fit because she wasn't doing the bed baths with them. And every day after, they made her life hell. She left. I think should would have made a good nurse too. It's a shame.

Dino-nurse said...

Thats so sad Anne. Years ago when HCAs were still called auxillary nurses there was no question that the qualified staff would help with basic care once they had completed the drug round, IVs etc. No one called RNs lazy for letting this be the case. With only 6 patients to care for, you could usually manage to help with at least a few of the bedbaths. The last time I was sent down to "sort out The Pit" as we lovingly refer to our MAU I was struck by how 2 of the HCAs were bitching OUT LOUD about all the bedbaths that they had to do. I took them aside and pointed out that in comparison to the workload of the 3 RNs (45 beds)they had a realatively easy task. Plus a lecture on professionalism and supporting your colleagues. They obviously didn't believe me. I then pointed out that if they wanted more responsibility they should do the training and get a PIN. Then the crash buzzer went off and all hell broke loose. Two RNs were dealing with the patient and had things well in hand. All the equipment was already there. An F2 was also in the bay so the rest of us were not needed (plus the crash team could be heard rounding the corridor). I suggested to the HCAs that they get on with looking after the rest of the patients. Filthy looks were given and then off the went, still bitching. I wrote them both up and asked them to stop by my unit after their shifts were over.

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Frustrated Fairy said...

I'm going to be a nursing student as of September 10...reading this blog I have to say I'm a little bit scared but I feel like I'm prepared for the worst.

Anonymous said...

Dear potential students here is a student mentorship conundrum - see how many of you can work out the right answer. Once upon a time there were two third-year student nurses talking. Nurse A said "I have passed all my exams with high marks, never missed a lecture and paid attention but I am worried because I am working on a hard ward and have a harsh and critical mentor who has a reputation for failing students". Nurse B said "I did the minimum amount of revision and just scraped through my exams. I sometimes skipped lessons and when I found lectures boring I read magazines instead of listening to the lecturers. I am not worried about failing because the ward I chose is quite an easy placement and by a happy coincidence my mentor is an old friend of my mum. Isn't that lucky?" And the million-dollar question is:- Which student was signed off by her mentor and became an RGN and which student failed to qualify? I wish I was making this story up but it is based on a real conversation. Isn't the mentorship system just fab?

Anonymous said...

A most interesting blog.
Some students just stand around all day with their arms crossed is a comment I have heard a lot. Sometimes I just want to say, lucky bloody them. I have never been on a placement where this has been possible.
I may be a larval nurse, but I still have that nurse part in my job title and work remit.
Hca's can be a troublesome lot. I do know that if I ever saw again some of the behaviour I saw on my first placement, I would happily wander down the official complaint path. I may have it slightly easier being older and male. But I think it can be real difficult to assert yourself in the proper manner, I also think there is a confidence thing at work and as training progresses it gets easier.
My usual tactic when entering a new ward is to actively seek out the worst jobs and do them willingly, you want that stoma bag emptied, sure I will do it, breakfast be damned. After a few days I start looking for more nurse learning experience type tasks and at that point I start withdrawing from the hca workload. If I ever do get a spare moment I will look for an hca and ask if they need a hand. I have already heard while on a placement that students are now being looked at as staff when it comes to cover and things look like getting worse.
And after 3 years I have the possibility of being a graduate unemployment statistic, even though the media bangs on about nurse shortages.
Happy days.

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Anonymous said...

Everytime I come close to applying to the local uni for the nursing course, I rembember your great blog and see sense!

I'm a HCA on a busy, acute med ward and proud of it, I work hard, support my RN's completely with as much as I can/ am allowed to do and we try to have a good team morale, even if we a little stressed at times. I do agree there are same lazy arse HCA's who drive me up the wall, yet alone the RN they are paired with, but it saddens me to see us all frequently tarred with the same brush.

Though I will freely admit I do try to steal the student nurses at times for assistance with washes etc the ones on our ward tend to spend about 50/50 ratio with us and the RN's and it seems to work well. When we get first year's arrive they are nearly always paired with us initially before being let loose with the nurses, though in long term can see how the student might find it harder to say no, maybe I'll be extra nice to them next time back on shift..

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Anonymous said...

Dino-Nurse(24 Feb 2010)'s story about the two HCA's who gave her "filthy looks" and "carried on bitching" after she had spoken to them made me feel so angry. How dare they treat a qualified nurse with such disdain? I was also shocked to read the story about a nursing assistant who actually refused to bring an obs machine to a patient's bedside when the nurse told her to. No wonder RGN's feel demoralised if they regularly have to cope with what the PC brigade would call "challenging behaviour" from some so-called 'assistants' on top of all the other stress. Who the heck is in charge on the wards these days? The NHS should show some backbone and discipline those particular 'support' staff (who seem anything but supportive) before patients' lives are put at risk.

Anonymous said...

Welcome to Hades Ward. New first-year student standing to attention, rigid with fear. Self-aggrandizing second-year student sprawled in relaxed manner behind the nurses station trying to impress the RGN’s with repetitive boasting. Tense third-year student bustling about managing a group of high-dependence patients. Hello, we have a visitor. It’s Mr. Norovirus! All hell breaks loose. Projectile vomit and diarrhoea is exploding from patients’ orifices right, left and centre. First-year student is in shock. Second-year student doesn’t bestir herself to actually do anything, just stands fascinated observing the action, her jaw dropping in surprise. Third-year student in plastic apron is frantically cleaning up one patient and praying she can get on to the next one before another eruption manifests. She has to ask second-year student three times to bring her some clean towels before the girl-wonder is galvanised into action. In fact the smart little first-year student who is more on the ball moves like a whippet and beats her to it. Charge nurse is busy on the phone supervising operations and informing infection control (or trying to avoid having to get own hands grubby) depending on your perspective. Yes, there’s nothing like a dose of Mr. Norovirus to sort the wheat from the chaff.

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