Saturday, 28 November 2009

Why has Nursing care changed?

Why aren't the nurses as visible? Why does no one answer my call bell? Why is so little getting done in the way of basic care? Why are so many nurses leaving? Why isn't the care the same that it was in 1980? Were the nurses themselves better back in those days?

Somebody actually decided to do a little research into these issues and determine just what exactly is going on.

You won't find any "too posh to wash" "too clever to care" "needs matron to knock them into line" and "it all went downhill when they started training at university" comments here. Not by a long shot. Not by a long shot. The person who wrote this article knows her stuff and did her research.

I won't post the whole article here (edited to add, I should really as this got way longer than expected) but please, please, check it out. So much is similar to what is going on in the UK.

Here are some excerpts in no particular order. These are just paragraphs here and there that I copied and pasted for those who don't click on the article. My comments in blue. I'd do more but I am getting kicked off the pc by the warcraft brigade.

*The burden of care for nurses, patients, and families has demonstrably increased since 1990.

*This situation has three fundamental causes. The first cause is a profound change in the nature of hospitalization, the kinds of illnesses and conditions of patients treated, and the level of care required. The second is the reorganization of hospitals, which has led to a reduction in the amount of time nurses spend in direct care of patients. The third is the lack of broadly accepted expectations about the caregiving responsibilities that family, friends, and patients themselves ought to assume, both in the hospital and at home, about how this care should be coordinated with the work of professional nurses and other nursing personnel, and about the appropriate ratio of direct-care nurses to patients. This report deals with each of these causes in detail.

*Pressures on families are particularly severe when a patient has been sent home from the hospital after a shortened stay or has received outpatient care for problems that were formerly dealt with in hospitals.

*Nurses report increasing dissatisfaction with their work in hospitals that have cut staff, that require frequent overtime, and that have replaced nurses with assistive personnel. Research has shown that these phenomena are related to adverse nurse and patient outcomes.

*This situation has three fundamental causes.

*The first cause is a profound change in the nature of hospitalization, the kinds of illnesses and conditions of patients treated, and the level of care required.

*The second is the reorganization of hospitals, which has led to a reduction in the amount of time nurses spend in direct care of patients. The third is the lack of broadly accepted expectations about the caregiving responsibilities that family, friends, and patients themselves ought to assume, both in the hospital and at home, about how this care should be coordinated with the work of professional nurses and other nursing personnel, and about the appropriate ratio of direct-care nurses to patients. This report deals with each of these causes in detail.

*Hospitals and hospital nursing have changed dramatically since 1990. Changes in reimbursement and demography have, in turn, added to the pressures on hospital systems, on patients, and on caregivers. Inpatient lengths of stay have declined dramatically (by 40 percent between 1980 and 1995) (Reinhardt 1996), and the average acuity of patients is higher in any given unit. Therefore, every patient assigned to an RN requires relatively intensive monitoring and care—a situation that is complicated by the fact that increased demands for documentation mean that caregivers can devote fewer hours to direct care and monitoring.
Try telling any of this to these old bats who trained in 1960 and haven't been back since 1962. One stupid bitch said that the problems were down to university educated nurses, and everyone else just repeated that statement like a robot.

*Advances in knowledge and medical and nursing expertise have enabled a greater number of seriously ill patients to survive. The shortened length of hospital stays, resulting from pressure from insurers (Or nu-labour targets), means that more severely ill patients are being discharged sooner to nursing homes, rehabilitation facilities, or their own homes. Moreover, the way hospitalization is financed and the growing number of chronically ill people and the aging of the population in general are also affecting hospitals' inpatient mission.

*Nurses, physicians, patients, and families have formed their expectations about care over many decades. Personal experiences, fictional depictions, and anecdotes from family and friends shape notions about care. The concepts care and nurse are both freighted with complex historical and emotional content. Seldom verbalized, this social legacy contributes to the public's expectations about caregiving. That the nature of hospitalization has changed, that demographic changes have brought different emphases to the health care system, that financial pressures have led to restructured and reorganized systems, and that hospitals have had to alter their mission to suit these financial and demographic shifts—all these developments have been received with gloom and anxiety by patients and potential patients and with concern by nurses and physicians.
Well it seems that everyone just blames the nurses for being lazy. Problem solved eh.

*Recent changes in what people can expect from nursing and hospital care have not been widely discussed with the public. Nor have changes been discussed with nurses very often.

**. Nurses represent the primary surveillance system in hospitals 24 hours a day. An adequate surveillance system provides enough nurses to observe patients directly so that they can recognize an impending or actual problem. These nurses are the first to mobilize an intervention that often requires the coordination of the activities of others, including physicians, to save a patient's life. Silber finds nurse staffing even more important than the board certification of physicians, since physicians are usually the second to know about a complication.

*****Consulting firms brought in to help hospitals reengineer their services and achieve cost reductions usually target labor costs. But nurses and physicians often complain that consultants do not seem to understand the complexities of delivering care or to grasp the complex role that nurses play in observing, monitoring, and assessing patients' needs. All too often, cutting professional nursing staff—and replacing nurses with nurses' aides or other assistants—serve as an easy solution to budgetary problems. This is exactly what is happening in the NHS.

*I once had a chance conversation with a man who, I learned, had in the past worked for one of the major consulting companies and had been deeply involved in the restructuring of a number of hospitals. Learning that I was a nurse, he said, somewhat sheepishly, "I'm one of the bad guys." He told me about what he described as his "naive and dangerous period" and was filled with guilt over the restructuring recommendations he had made in his former job. His awakening, he said, had come when his wife had had a baby who required intensive, long-term neonatal care. During the hours and days the couple spent at the hospital visiting their critically vulnerable infant, they had a chance to see nurses at work expertly caring for—and ultimately saving—their child. In the process, he came to understand what nurses do and how important their job is. Well well well. NHS hospitals have been bringing these same kinds of management consultants in for years. Doubt they are remorseful though. They are just out of control. Prejudice against Nurses leads to managers listening to these clueless dipshit management consultants rather than frontline staff who know the score. It's the same everywhere, doesn't matter what country you are in...

*The word care has a variety of meanings, and is used to describe both personal and professional activities. But the professional care that nurses are trained to give is in many respects quite different from the personal sorts of caring that characterize relationships between spouses, parents and children, family members, and friends. Professional caregivers are independent decision-makers, whose autonomy of action is legally defined, and they are highly educated specialists who act in accordance with expert knowledge and in ways appropriate to their responsibilities.

*When a person's daily life is seriously impaired by illness, age, or disability, he or she may require the assistance of nurses—whether in a hospital, a nursing home, or at home. Unfortunately, many ambulatory settings are poorly suited for nursing activity, a situation that calls for an even higher level of professional knowledge and judgment.
In other words, care—the kind of care that nurses render, sometimes under difficult circumstances—consists of much more than giving patients confidence, assurance, and comforting words. Nurses base their practice on exacting professional standards.

*The complexity of the care given by professional nurses, however, is only poorly understood by the public at large. . Because "caring" is such a ubiquitous concept, and because the word is used so loosely, nursing care is often seen as intellectually undemanding, a "soft" profession. And this perception has been bolstered by the fact that historically, and in many nations, young men have been forbidden or discouraged from entering nursing, leading people to see nursing as "women's work" and a second-class kind of career. That nursing has been so demeaned has led men and women both to discount it, rejecting careers in professional caring for more powerful, economically rewarding roles.

**Chief nursing officers told Gordon that nurses' greater workloads occurred mainly because patients were in and out of the hospital so quickly. Administrators said the same thing, but their agreement did not seem to translate into support for bedside nurses. Staff nurses complained of a lack of support from nursing administrators and said they felt they were reliving failed nursing delivery models of the past, such as less expensive substitutes and team nursing.(Oh Nurse Anne could tell you all about that) They said administrators blamed them for being inefficient, dismissed them as complainers when they reported problems in patient care, and constantly challenged data culled from their daily experience in providing patient care

*In addition, Sovie's study reported a declining number of RNs involved in direct patient care and a growing number of UAPs participating in patient care. (The study also showed that UAPs are being assigned an expanded role in providing patient care.) Although reductions in the number of RNs were intended to reduce costs, Sovie's findings showed that costs per day/discharge were influenced by hours worked per patient day (HWPPD) and paid full-time equivalents (FTE). Thus FTEs and HWPPD were the expense drivers, not the percentage of RNs. In many instances, as RN percentage went down, both FTEs and HWPPD rose since, with fewer RNs and more unlicensed personnel on staff, it took more people more hours to deliver care.

*The majority of these changes were cost driven; however, costs per day/discharge decreased as the percentage of RNs increased. That reengineering does not necessarily improve performance but can in fact be detrimental to it was also found in a study that examined cost per patient day at 2,306 urban medical/surgical hospitals with 100 or more beds (Walston 1998).

*It is difficult to ascertain the overall skill level of nursing staff at restructured hospitals. The American Hospital Association stopped collecting data on aides in 1993—just as hospitals had begun substituting aides for registered nurses—because, it said, hospitals balked at completing the survey (Aiken 1999). The AHA still collects data on RNs and LPNs, but, as aides are melded with other hospital personnel, it is no longer possible to calculate the nursing-skill mix.

*The training of the aides who are replacing RNs is not regulated by state licensing boards. There are no minimum requirements governing the amount of training aides or "cross-trained" workers must have before they can be redeployed (at least part of the time) to do nursing work. Training periods can range from a few hours to perhaps as long as six weeks. Ninety-nine percent of the hospitals in California reported fewer than 120 hours of on-the-job training for newly hired ancillary nursing personnel. Only 20 percent of those hospitals required such aides to have a high school diploma. The majority of hospitals (59 percent) provided fewer than 20 hours of classroom instruction, and 88 percent provided 40 or fewer hours of instruction time (Institute of Medicine 1996).

*In April 1999, nurses at several New York hospitals went on strike to protest patient loads and work hours that they deemed dangerous. In a complaint to the National Labor Relations Board, the New York State Nurses Association reported that nurses were sometimes working 20 hours out of 24 and caring for as many as 18 patients (New York State Nurses Association 1999). Many other reports tell similar stories: of nurses dealing with ratios of 1 RN to 10 patients on the day shift and 1 to 15 or even 1 to 20 on some shifts (well that sounds almost as bad as what is normal in the UK, those are our regular numbers), of nurses being expected to work double shifts, and of a growing demand that nurses work mandatory overtime.

*Anecdotal reports from nurses, doctors, patients, and families suggest a dramatic decline in the availability of professional nurses to care for acutely ill patients while hospitalized and during the immediate post-discharge period. Most of these anecdotes contain bitter complaints about the lack of nurses to meet the increasingly complex needs of patients and express genuine concern (often outrage) about the decline in the quality of care provided to vulnerable patients.
Mostly this outrage is directed straight at nurses who are caring for way too many patients at one time. Nurses are told that the failures in care are down to their laziness, their stupidity, their uncaring slovenly attitude.

* Nurses, physicians, and chief nursing officers all agreed that they could no longer provide the level of care given in the recent past. Both nurses and physicians reported that heavy workloads caused nurses to postpone or miss tasks, and nurses described a troubling erosion of their capacity for empathy because of the difficulty they had finding time to provide even basic physical care. The combination of crowded schedules and inadequate staffing permitted little or no time for education or mentoring of neophyte nurses.

*The experts did, however, make the following positive recommendations for action by public-sector regulators:

Establish standards for safe patient care, while acknowledging the extraordinary difficulty of doing so.

Establish training standards and competency (certification) exams for previously licensed personnel, through both national and hospital-based strategies.

Find new ways to regulate the sites in which nurses practice. Such regulations might include requirements that address the issues discussed in this report (for example, closing beds when RN staff is reduced below a particular level and adding clinical nurse specialists to units).

Require that clinical assignments be given only to persons qualified to perform them.

Require that all staff performing clinical tasks be properly identified.

Encourage state legislatures to establish commissions on nursing to address issues of regulation as well as the adequacy of the supply of nurses, as has occurred, for example, in Maryland and California.

Create a nursing assignment registry that provides information about training and background in ways that earn the respect of members of the profession and others.

Establish licensing requirements that reflect the different capabilities of nurses with different educational credentials, in response to employers of nurses redesigning jobs and rewards that reflect differences in education.

*The experts offered the following recommendations to address the issues:

Adopt the ANA Principles of Nurse Staffing, either as an industry standard or by regulation.

Require hospitals to report nurse-to-patient ratios publicly on a regular schedule. (Note: This is not a recommendation of required nurse-to-patient ratios.)

Establish protocols to prevent the circumvention of technologies designed to prevent medical errors (for example, turning off alarms that would alert staff to problems).

Establish a more effective standard hierarchy of expertise in nursing service; in particular, establish as a norm the strong presence of persons with substantial recent clinical experience at the highest levels of management as well as in team leadership in patient care areas.

Provide opportunities for education and career progression for all hospital positions. Encourage hospitals to improve working conditions in order to be eligible for Magnet Hospital Recognition, awarded by the American Nurses' Credentialing Center.

The experts recommended that policymakers in government, provider associations, and nursing should:

Improve working conditions, compensation, and benefit packages for nurses to encourage long-term institutional employment, so that nursing can compete more effectively with other professions.

Tie repayment and forgiveness of educational loans and grants to the recipient remaining in nursing, in hospitals and other health care agencies, for periods of time related to the extent of support granted.

Make nursing education more efficient by reducing the number of nursing schools in hospitals and community colleges and increasing capacity in baccalaureate and graduate degree programs. See my posts on patients of degree educated bedside nurses having highter survival rates.

It's an excellent article. It's not that long. You can read it in 5 minutes. Check it out of you get a chance. I am so sick that the changes in nursing care in hospital being blamed on uncaring, overeducated, lazy nurses. Nurses are just a soft target eh? Why is that? Why is it so easy to target Nurses? That answer can easily be found in the history of Nursing. That's a blog post I am still working on.

Thursday, 26 November 2009

Nice Headline about Nurses Daily Mail

No doubt whatsoever that there were issues with Nursing care at Basildon.

With the kind of trained nurse to patient ratios that British nurses are working with I am not surprised. I wouldn't expect a nurse with superpowers to do any better. I have worked in 3 countries as a nurse over a period of 13 years. Let me remind you of something. Nurses in the UK are working with trained nurse to patient ratios that wouldn't be legal in a 3rd world hellhole like Haiti. Not only that, but they have a lot less back up than say a nurse in Canada or Australia would have.

I once asked asked a super american nurse friend of mine if she would take on 15 acute patients. She is a bedside nurse, very well respected and has won multiple awards. She would tell you no way would she take on more than 6 acute patients with no back up because it would be nothing but a total fail, no matter how hard she worked. She would refuse to work in a hospital like mine that can assign a nurse anywhere from 10 to 30 and upwards patients. This statement came from a nurse friend of mine in the North East USA who won an award for most compassionate nurse at her Magnet Hospital. Google Magnet.

No one in their right mind would expect a nurse to be able to function in the conditions that NHS nurses are working in right now. Whether they are angels or devils, they are going to fall flat on their faces and fail. Therefore we can conclude, once again, that most commentators on the daily mail are lunatics.

I'll let my readers take this apart in the comments section. I don't have the energy right now.

What have I learned from this article? Journalists still don't understand that most of these "nurses" are not actually nurses.

The daily mail is such an extreme example of Yellow Journalism that it would even shock William Randolph Hearst with it's vileness.

I also take offense to the fact that they are depicting nurses as lazy. If you are an RN in acute care you WILL be working many 12-14 + hour shifts without taking any kind of a break. The health care assistants and clinical support people running around in their nurses uniforms don't go through this but Nurses often do.

12-14 hours without a break or a drink, on your feet while the support assistants stop for tea. It's not like they can help you keep up with the nurse stuff anyway. Remember that most of the readers commenting on this daily fail article probably work 8-9 hour days and get an hour lunch break. Now that is lazy.

Dear Daily Fail,

Interesting piece. I will never so much as have a minute free in shift to screw around with mattresses. If the hospital will provide more staff nurses on shift with me to handle all the drugs, treatments, assessments, orders and accountability then I will happily clean the mattresses. Happily. God I would love a shift spent cleaning and I am very much a degree nurse.

There is a massive difference between a nurse not cleaning a mattress because she is alone and cannot drop the ball on the drugs and the treatments for 30 seconds and a nurse that just doesn't want to do it. The former is a lot more likely and the latter is rare. Cleaning mattresses rather than being the only RN for multiple acutely ill patients sounds rather pleasant to 99.9% of us. You see, we would consider an 8 hour workday without life and death responsibility a vacation day with a paycheck. Especially if it was an 8 hour workday without life and death responsibility and a lunch break. Even if it was only a 10 minute lunch break.

This is what we think of people who work outside of health care and un-registered people who work in health care. You are all having permanent vacation days with paychecks. A nurse I used to work with who left health care to work as a teaching assistant explained it to me that way and so have many others.

An RN can be working at a pace you cannot begin to imagine sometimes for 14 hours straight with no break and still only get through the top 1% of what needs to be done that shift. That means that even if he is working at that kind of pace most of his patients will languish and not get fed or basic care simply down to the fact that the nurse is so outnumbered by people who need help.

I am starting to realise that it won't actually matter if I stop for 5 minutes to get a drink during my 12 hour shift. It won't change a goddamn thing.
Patients are going to suffer whether I do or don't.
Get a safe trained nurse to patient ratio campaign going on or shut the fuck up.

Sincerely Yours,

PS- no one believes that you care about patients. A sustained media campaign to expose the reality of the situation and staff our hospitals with trained nurses would result in a level of care that would have made the idea of starving neglected patients on filthy wards a distant memory. It would also be cost effective to increase your ratios of trained nurses. But that wouldn't give you sensationalist yellow journalism headlines now would it?

By the way does anyone know of a casualty unit anywhere in the NHS where the actual nurses could afford to be lazy for even 10 seconds and then get out of there without being blamed for someone's death?

Tuesday, 24 November 2009

Last post on Nurse Degrees....for awhile anyway

We're all sick of arguing with nutters like Iain Dale and others who worked in a hospital they say...... and weren't even bright enough to realise that they weren't actually any thing like a Nurse.

But I am posting this next piece because I think the author sums it all up quite nicely. This was written by a colleague of mine.


I'm about a week behind the curve on this one, but I've been browsing through all the blog reactions to the news that all nurses will study for a degree from 2013, and alternately laughing and crying.

This is a desperately unfashionable thing to say, but I actually think it's a good thing. I trained in Wales, where nurse training is already all-degree. The news is only bringing England into line with Scotland and Wales. Contrary to what a lot of commentators are suggesting, doing a degree doesn't mean you spend less time on the wards while studying - whether you do a degree or a diploma, a student nurse has to spend over 2500 hours out on clinical placements before they can qualify.

Here's what Iain Dale (described as "insightful, informative and entertaining" by the Observer) has to say about it, in his insightful and informative way.

I once spent a year working as a nurse. There, that surprised you didn't it? Admittedly it was in Germany and was in a private clinic specialising in spinal injuries, but it was still nursing. I had no qualifications, no training and certainly no degree (it was my gap year).

So, Iain, you weren't a nurse at all. You were a care assistant. Don't get me wrong, I'm not knocking care assistants; many of them are brilliant, but they're not staff nurses.

So when I heard this morning that the NHS was now going to insist on a degree before nurses could train, I was dumbfounded. Not all nurses are academically gifted and would want to do a degree. Does a degree in astronomy make a nurse better able to do his or job, than four years hands on training?
Nooo, Iain, they have to do a degree in nursing, not astronomy!

Then there's this guy, who despite being a doctor, still doesn't seem to understand how nurse training works.

The same is the case for nursing training, the ward hours and apprenticeship has been lost at the expense of satisfying politically correct mumbo jumbo spewed forth by educationalists.

But the ward hours and apprenticeship haven't been lost. I'm a degree-educated nurse, and I still had to do my 2500 hours on placements before I could qualify. I spent a hell of a lot of time running around wards doing hands-on nursing to get my degree.

Then I read Melanie Phillips article in the Spectator. Yadda yadda nurses don't want to nurse yadda yadda Florence Nightingale yadda yadda nursing is a vocation not a profession yadda yadda ...then I had to stop before my brain exploded onto my PC monitor. Though I understand this is a fairly usual reaction to reading a Mel Phillips article.

Right now there are many problems with providing nursing care, just to list a few:

- criminally low ratios of nurses to patients on NHS wards. I've heard of some wards where 2 nurses and 2 healthcare assistants were left looking after 35 seriously ill patients.

- more form-filling being forced on nurses in an increasingly lawsuit-happy culture - see also teachers, police officers and social workers

- advances in medicine making the job more technical. Florence Nightingale wasn't running around dealing with IVs, catheters, tracheostomies, all the while mixing potentially lethal medications

- an ageing population making the patients on the wards older and sicker, thus needing more care to keep them alive.

But what is not the problem is that nurses are getting too uppity because they've got degrees. All this is inverse intellectual snobbery that says that clever people can't be good nurses. My experience is that clever people often make for outstanding nurses. They think on their feet, they can problem-solve, they look at new ways to do this, they keep their knowledge and skills updated. All of these things are good qualities in a nurse.

As for the media stereotype of nurses who are too busy daydreaming about their next sociology paper to notice the patient's call bell ringing....they may well exist, but I haven't met any of them. What I have met repeatedly though is nurses who were rubbish at their job because they were ignorant, unimaginative and thick as a plank.



Melanie Phillips article here. Melanie, your ignorance is shocking. That goes for you too Iain Dale.

Monday, 23 November 2009

Minette Marrin revisited: She's still doesn't have a clue.

Minette just wrote an article for The Times. Check it out. I do not believe that she did one iota of research. She doesn't seem interested in getting the facts across. She seems more interested in getting a reaction. Okay I'll feed the troll. I am starting to believe that The Times is a worse example of journalism than the daily mail. Neither the times or the daily fail will acknowledge any letters or offers to write from Nurses who actually understand the situation. If they do, they get a nurse who retired 19 years ago which is pointless really because they don't have a clue. The only one that comes close to trying to present both sides is The Guardian. And believe me, it is tough for me to throw a compliment out towards a liberal anything. I wrote this in 5 minutes as that is all I had to get it in on time and felt I could have done better but I appreciated the fact that they published it.

We first met Minette here. Let's take her latest on nursing apart. It's so vile that I am typing with gloves on. The blue text is mine. The rest is toxic waste.

One of the government’s sillier initiatives was its announcement last week that in future all NHS nurses must have a university degree. From 2013, all would-be nurses will have to have taken a three- or four-year university course to enter the profession. The disastrous consequences of this ought to be obvious to the meanest Whitehall intelligence.

No change there then. You see Minette, for a person to become a legally obtain the title of Nurse and work as a Nurse....they already have to have 3 to 4 years of Uni under their belt either diploma or Degree program. And they have to put in thousands of clinical placement hours doing basic care and much more in order to earn their degree or diploma. Nursing care on the wards has gone south when management decided to replaced real live nurses with health care assistants. Health care assistants have no training, no education. They are not nurses in anyway shape or form. Just because someone works on a ward providing care and wearing a uniform does not mean that they are anything AT ALL like a nurse. Ian Dale and that dude who writes for Devil's Kitchen both say they worked as care assistants. They tell people that they were "nurses" once and are deluded into thinking that they have some kind of insight.

All sorts of people who might make excellent nurses will be put off, and lost to nursing: anyone who is not particularly academic; anyone who — frankly — is not particularly bright; anyone who has a vocation to care for patients without wishing for the most high-tech training; anyone who is unable to take on a mass of student debt on a nurse’s poor pay; any late entrants — and this at a time when the NHS is desperately short of nurses.

Minette. If they are not particularly bright they are not coming anywhere near me as my registered nurse when I am a patient on multiple infusions etc. I have seen too many deaths as a result of stupid mistakes by RN's. Hospitals don't want to hire registered nurses anyway. All they want to do is hire care assistants. Care assistants require no education or training, take no responsibility and are in a position to do more in the way of hands on care. And they get to wear a nurse's uniform. As a matter of fact if you want to care for patients without having to get an education or deal with anything technical then a career as a health care assistant is for you. A health care assistant also has a much better chance of obtaining employment on the wards.

Rare though it is for me to agree with any trade union, I believe the nursing unions Unison and Unite are right when they say that there is no “compelling evidence” that degrees for nurses would improve patient treatment.

Yes there is much compelling evidence. Do your research. Here and scroll down. Since when did Unison or Unite say anything intelligent anyway? Seriously. What the fuck do they know about any of this?

I have come across a great deal of anecdotal evidence quite the other way: that nursing degrees on a university campus with too little practical hospital experience have recently been producing graduates who are all too often, in the words of one consultant, “a liability on the wards” — not necessarily “too posh to wash” but often not much good at it, or at the important clinical observations that go with it.

Degree nursing programs are 50% practical hands on experience on the wards and 50% theory. They have to do thousands and thousands of hours of hands on practicals to earn their degrees. Otherwise they fail and do not graduate. Remember that nursing students at university spend much more time in class and on coursework than their non nursing fellow students. This is the case whether you are a diploma student or a degree student...the only two ways to actually become a Nurse.

And on top of that they have to do something like nearly 3000 hours of clinical placements. Any nurse taking 10, 15,20 patients is going to fail miserably. She can't read the charts, she is being constantly interrupted, she has to accomplish any task that comes her way in the 30 seconds she has between interruptions. Your dumbass consultant friend doesn't have a clue either. He is thinking back to the good old days where ever shift had a nurse in charge with a team of staff nurses providing care and he is comparing today's nurses (who are working alone often in horrid conditions, and sicker patients in a more chaotic environment )with his memories.

To say this is not to dismiss the value of demanding degree courses for any would-be nurse who is suited to intense academic and technical study. Such nurses should be able to take degrees and already can, though one might argue about the nature of the present courses: more than 25% of nurses already hold a degree.

Minette. Anyone who obtains the legal title of Nurse is going to be left alone with too many patients making critical life and death decisions. He is going to have to think fast, and think on his feet. He is going to have to have a hell of a lot more knowledge to do his job than a teacher, PC etc. That is why nurses in other first world countries are paid much more than teachers, policemen and social workers. Oh yes they are. A real nurse working in acute care will have to multi task and prioritise in a way that you are incapable of understanding. You do not fuck around with people's lives.

You seem to think that every person working on the wards providing care is actually a nurse. I think that you are assuming that all the health care assistants are some kind of junior nursing division. You are wrong wrong wrong. Anyone who earns the legal title of nurse will find themselves virtually alone on a large ward with only untrained care assistants who cannot do much. This is what you have to remember.

If I am a nurse on a 36 bed ward with 5 other nurses on duty then I have 6 patients to assess, medicate, take off orders, and care for myself. If I am a nurse on a 36 ward and my 5 colleagues are care assistants rather than nurses, then I have 36 patients to assess, medicate, take off orders, and care for myself. Have you ever tried to even keep the names of 36 people, their medical history, their diagnosis, lab tests due, and drugs straight for 36 people? Impossible. But this is the staffing matrix that management insists on. This is the current situation. This is the shit storm any newly qualified nurse is walking into.

I don't see you or the public up in arms about this. If you want nurses to provide care then why aren't you demanding that your hospitals staff the wards with nurses? You are the service users. So am I. That is why I am fighting.

However, not all would-be nurses are suited to a university degree; just as people vary hugely, so do nurses, so do the nursing roles they are fitted for and so does the training that suits them best. Plenty of the best bedside nurses are not academic, and much essential nursing work does not depend on the dizziest heights of training. There is more than one way to be a “supernurse”, and a degree is not enough.

Are you talking about health care assistants again? No, they don't need a degree and never will. They are the only people that the hospital wards will hire thanks to tight managers. But they cannot do the job of a nurse, so the few nurses left are just covering a larger number of patients who are sicker than ever. A caring, empathetic but thick person would be a disaster as a bedside nurse, but okay as a health care assistant. Remember that anyone who earns the title nurse will be left on their own making critical decisions that require a high level of knowledge. That is what being a bedside nurse is all about these days thanks to disgustingly poor understaffing and increasingly acute patients.

As the nursing unions said last week, “The emphasis should be on competence, not on unfounded notions about academic ability.”

The person who said that is brain dead. He/she does not understand what bedside nursing actually is, and probably confuses bedside nurses with health care assistants. Again.

The health minister, Ann Keen, has been making predictable noises about providing higher-quality healthcare, but the real motivation beneath all this, quite explicitly, is the desire of the Royal College of Nursing and the nursing establishment to raise the status of nursing, and to end the stigma of the “doctor’s handmaiden”.

No what we want is safe nurse patient ratios. I want a small enough number of patients to each Nurse. That will allow her to get the difficult stuff out of the way and do basic care herself rather than have to delegate to health care assistants because she has over 50 IV drugs and to give, a bleeder, and no one to help. The health care assistants cannot help me with drugs, bleed outs etc. I am managing that on my own for 36 people and the doctor on call is ignoring my bleeps. Guess who takes the fall when it all goes wrong. Me.

Nurses — or rather those who claim to represent them — want to have the status of professionals, on a level with doctors, and part of being a professional is having a degree. So nurses must have degrees. All of them.

All real Nurses needed to go through a hellish training at university already and it is very academic. Nurses are going to be working in chaotic situation that teachers and social workers cannot even begin to fathom. People die if nurse screws up. To call themselves nurses they must be registered with a professional body, the NMC, act like professionals and follow professional guidelines. They are accountable to society, their patients, their colleagues, and their professional body. They will be prosecuted in a court of law for a math error that harms a patient. And you don't want to call these people professionals?

So nurses must have degrees. All of them.

All of them indeed. For god's sake love. Your average 35 bed ward is only be staffed with one or two nurses anyway. The other 3 or 4 staff will be health care assistants. That means that even if all nurses have degrees most ward staff providing care will NOT have degrees. Let's see..what do we often have on the ward per shift as far as staffing... one nurse (either degree or diploma) on the ward and 3 care assistants....that would mean that only 1 out of four members of staff are actually trained and educated, even if all nurses have degrees.

They are saying that all nurses will have degrees, not all ward staff caring for patients. The term nurse is not a word that you hand out to anyone who takes care of people, unless you think it is still the year 1846. Nurse is a legally earned title. You are giving people the idea that all ward staff providing care are called nurses and will be degree educated. Not by a long shot love. A few weeks ago a patient of mine asked the health care assistant a question. She did not know the answer. "Damn nurses with their damn university training don't know a damn thing" said the patient. I jumped right in there and pointed out that the young lady was not at all a nurse and has had no training. Then I answered his question. Management brought the health care assistants in. Management did it. The nurses fought this tooth and nail. We lost the fight.

What’s particularly depressing is that this obsession with status is not unique to the nursing establishment; it has become a national obsession, of which this is just one expression.

It’s what explains the feeling that everyone must go to university now and the government’s determination to turn 50% of all school-leavers into undergraduates, regardless of the consequences. (There have been some suggestions that the government welcomes the idea of sending all nurses to university because it will effortlessly bump up the student numbers closer to the promised 50%.) When I was a child only very few people, and only those of supposedly high learning and intelligence, called themselves professionals and had concomitantly high social standing. Now, increasingly, everyone is described as a professional, even journalists occasionally.

No journalists are not professionals. You have to have some kind of moral code and be held accountable for unethical conduct to be considered a professional in my book.

If you want to read any more of Minette's rubbish
here you go. Don't forget to check out the comments section. We are going to have a militant medical nurse competition. Post the dumbest comment that you can find from Time's readers and will can post them here and vote.

Sunday, 22 November 2009

Message from An Ex-Nurse friend of mine

RN's are leaving the wards in droves. A small number are going into nurse practioner and pen pusher type roles. A larger number of us are perfectly happy to take pay cuts to get the hell out. Lucky for us our husbands and partners tend to not work in health care and are generally the breadwinners.

The following is a message I got from a friend when I poured my heart out to her and it is an example of the types of emails I get all the time at militant medical nurse.

"That's why I got out of nursing. I let my RN license lapse when Becky was little, got a job as a secretary at a car dealership on minimum wage and felt so relieved.

When I worked in maternity on night shifts and if weren't busy they would pull me and send me to be in charge of a medical-surgical floor where I knew no one and nothing about medical-surgical and there were forty patients! And then the doctors were so mean and arrogant! I knew one doctor who said she deliberately wrote orders sloppily so she could read it any way she wanted if she was ever called to court, thereby letting the nurse take the fall. Their abuse of the nurses was horrific, and the patients were worse. I admire you for what you do. I know it's so hard the way things are set up. Aimee is thinking of nursing as a career and I tell her to do something else! I would never go back if I was starving even. Believe me I have had my share of financial troubles. But I won't go back. Take care

This is from a nurse in North Carolina, where the pay and working conditions are generally much better than what you see in the UK. No wonder UK nurses are or two become doctors, a few find jobs in the community, the rest escape healthcare altogether and so on and so on.

Friday, 20 November 2009

Doctors: Know Your Place Shut Your Face

Many doctor bloggers are talking a lot of shite. They seem to see the degree nursing issue as a threat and are convinced that BSc nurses want to be doctors. What a load of horseshit.

In Witch's post it was mentioned that apprenticeship is going out the window. If anything it is growing and will continue to do so. Even now there is usually only one or two trained nurses on the ward and everyone else is an untrained apprentice getting on the job training only. They are not training to be nurses yet as that is years away. They are training to be health care assistants. Theyhave the option to go to uni later on and train as a nurse using credits from their apprenticeship. Nice people a lot of them but the lack of knowledge is scary. Most of them have no desire to actually become Nurses.  They don't want to deal with the stress, the drugs, doctors, emergencies, etc etc.

Their lack of knowledge is appaling. That is because apprenticeship style training only is crap. Most of them are very nice to the patients. But then they do something stupid like open an IV pump up and take the tubing out (so that they can change a patient's gown and weeve the IV line through the sleeve) without clamping it...when potassium is infusing.  They don't understand a thing about heart failure and tell patients on furosemide that the sure do wee a lot.  Stupid things like that.

Let's be honest: Doctors do not know anything about nursing, nursing issues etc etc. Nursing is a completely different science and profession from medicine. Please stick to diagnosing, prescribing, where to get the best cocaine and cheating on your wife. Leave the nursing issues to the RN's.

 Let us nurses talk about education levels for nurses,

Let 's get some facts straight.

Degree nurse does not equal nurse who doesn't believe in doing basic care herself. Quite the opposite.

My university  required us to be in the top 10% of our high school class and have two years of university level science and math with top grades to get into their nursing program. They had 50 applicants for every one place each year. We were taught by masters (and higher) degree nurses who taught us the importance of being good bedside nurses.
The university nurse training in England has as much on the job training as the old style training did.
When California instituted nurse patient ratio laws ensuring that each degree educated RN have no more than 6 patients in hospital (ensuring that the RN can nurse them properly and avoid malnutrition etc) the number of applicants to their nursing program that year rose dramatically. Something like 80,000 RN's came back to the workforce as well. To do bedside nursing. Yeah.

Anyway I responded over here with the following.

Degree trained nurses are not taught to be above basic care. They get plenty in the way of hands on placements. They are always on the wards for weeks and weeks at a time.

There is not such thing as "the modern nurse who thinks she is too posh to wash". That is a myth perpetuated by fuckheads who don't know better or cannot understand the situation. I am degree trained, have nursed for many many years, and have worked with many new grad nurses.

I have yet to meet any highly educated nurse or any RN who thinks that he is above basic care. Most just are not in a position to do it. So I am thinking that maybe you are just a liar, or a goofball repeating statements that you don't understand.  To posh to wash nurses must be out there someone, but they are rare. It's not something I run into as a bedside nurse among other bedside nurses.

I trained at a well respected nursing school in the northeast. I had to have two years of uni level science and math and top grades to even be considered for their nursing program. I was able to take it together and stay in if my grades were high enough.. And even then they had over 50 applicants for every one place.

Our nursing instructors had masters degrees in nursing, doctorates in nursing and PHDs.
They taught us to be bedside nurses. They hated the medical model of care.

They taught us that hospitals should not be using care assistants instead of RN's and that highly educated nurses should do all care. They taught us that if we didn't do basic care ourselves that are patients would not be assessed properly and that would lead to poor outcomes. They taught us that nursing was a completely different science to medicine and that we were nurses not junior doctors. They hated the whole diagnose and prescribe thing like the devil hates holy water. Their degrees were in nursing, not  medicine.

These same instructors, despite holding master degrees and higher still did shifts at the hospital as bedside nurses. They attended our placements with us, and needed to be up to date. Therefore they stayed in touch with basic care and reality.

Not every school of nursing is this good but they should all be. 

They taught us that if we were ever working in facility where we were taking on more than 6-8 patients at a time that we needed to get the hell out of there and find a new job. "If you are working for a hospital that makes you take 10+ patients you will have no choice but to triage and delegate all basic care to care assistants. THIS IS BAD. Never EVER work for such a hospital". These were nurses with masters degrees who were teaching us these things.

"such a hospital" is every fucking hospital in the NHS and most of Canada and the USA.

The new grad nurses are very well aware that people think that they are too posh to wash. When patients are having an acute atttack of CCF and are short of breath these new nurses are putting people on bedpans and handing out meals rather than notifying the on call and getting orders because they are so afraid of being labelled as "uncaring" by visitors, health care assistants, and guys like you.  How sick is that?

Remember you only have one nurse for a large group of patients. If she isn't getting the diuretic drug etc for the heart failure patient who is going south then NO ONE is.

You wouldn't believe the scare stories that are happening because many of these new grads are on a mission to prove that they are not to clever to care and all that. I have seen patients with an HB dropping faster than a hooker's knickers not get intervention nor their blood  transfusions etc for hours and hours because the lone RN was getting grief off of visitors and patients for not getting the bedpans out fast enough.

You people need to stop it with this bullshit (perpetuating the myth that degree nurses are not into basic care) because people are getting hurt

I don't like your link but agree about NOT using degree nurses as pseudo docs. Is that clear?

Forget about the practitioner thing. I never met one personally. Even though I know many highly educated nurses I don't know of ONE who wants to be a practitioner. Not one. Not one.  I know they are out there but I don't think that they are as common as you fear.
If they forced all of us degree nurses into the practitioner role the vast majority of us would get the hell out of healthcare. Most degree nurses have no desire for the  frat boy, medieval world of medicine. Let's be honest: Medicine is simply about you guys swinging your dicks around to see who has the biggest one. No thanks. If I want to make more money I can uproot the family and go abroad and work as a nurse. Registered Nurses in other industrialised nations make more money than junior doctors in the UK.

 Read here and scroll down if you want to see how ratio laws requring degree educated nurses at the bedside with a very small number of patients brings RN's into the workforce and back to the bedside. And when the article in this link uses the term "Nurse" they are referring to university educated RN's.I agree with the doctors when they say that we should all just stick to what we know professionally. I will blog about issues in nursing and you guys please stick with the medical stuff. Blog about what you doctors know. Things like cocaine, philandering, cocaine, philandering, cocaine, philandering.

Re-Edited on 10/1/10 because of the glaring errors that result from my inability to type as fast as I think.  Notice that I did not take out the stuff about frat boys, cocaine, and sex addiction.

Thursday, 19 November 2009

More on Degree Nurses

Want to fly into a violent rage? Or bang your head into a wall over the fact that some people have no clue? Read some of the comments here.

There was one good comment.

I haven't yet had the balls to look at the daily mail and their readers take on all this.

Thursday, 12 November 2009

You will Need a Degree to become a Nurse

We just had a death in the family of the canine type, I have been reading BBC have your say, and I am in a real bad mood.

Here is the BBC article you have all probably read. I have been in mourning so I am behind with all this.

Here are the fucktwits on have your say.

I am in two minds about nurses being required to have a degree to qualify.

Let's talk about the pros first.

First of all a hell of a lot of research has shown that the patients of well educated bedside nurses have higher survival rates. Anyone who qualifies as a nurse will be thrown into a situation where he is own his own dealing with complex stuff, making life and death decisions and having to think fast on his feet with no second chances almost immediately upon qualifying. He will have to handle all this whilst getting interrupted on every 30 seconds or so throughout a 12 hour shift. Support? What a fucking joke. He will be the lone RN for a large number of patients with only untrained care assistants to help. This is how it's been for years. The matrons sure as hell won't come any where near the wards and it will be rare for our newly qualified hero to be on duty sharing a patient load with another qualified nurse to guide him. This is how it has been for years and it is getting worse.

Why are people in this country so silly? Why do they seem to have a death wish? If you don't think that your RN needs to be well educated as well as have a manageable number of patients you must have a death wish. You must want to die. You certainly don't really understand what a nurse actually is.

When I was overseas many patients would throw their registered nurse out of the room if she didn't prove on the spot that she had a university education. "Are you a BSN" "No sir I trained under the old diploma program" "Then get the fuck out of my room lady". Sad but true. Our older nurses are some of the best simply because they have decades of experience behind then and have proven that they have the tenacity to hang on in this hell profession. But people over there seem more switched on and seemed to have more of an understanding of what a nurse actually is. People in the UK do not understand what a nurse is.....

The old ways of training turned out good nurses for their time. The nurses that trained that way who are still practicing are excellent. They have decades of experience behind them and have grown with the changes. If you tried to train today's nurses like that however you would increase hospital mortality rates. The old training would not suffice now. As someone who has a strong desire to live and who will be a patient some day I have thought about this a lot.

I would thr0w a caring and empathetic nurse who couldn't get through pharma maths at Uni out of my hospital room . I don't give a goddamn about how caring or empathetic you are. I want to stay alive. If you are a caring and empathetic but not that bright I have less chance of surviving my hospital stay. I hope you are caring but first and foremost I want you to be on the ball because I know how much information you will be analyzing and how fast you will be moving and it is scary. I say this as someone who has been a nurse for well over a decade. I say this as someone who has seen patients die because their caring nurse was off helping hand out commodes. I say this as someone who wants to live.

Let me link to it again in case ignorant sickos like Jeremy "But what about the caring"Vine happen to be reading. It's all in the link...just scroll down. Or google nurse education and mortality rates.

Research has shown over and over and over again that hospitals that have a higher proportion of well educated nurses on staff providing direct patient care have higher survival rates.

If I had a registered nurse caring for me who didn't catch onto the fact that I was going into renal failure or was pre -arrest because she was lovingly off somewhere else bathing and making cups of tea for her other patients I would get her sacked and get her license revoked. I would also have a strong desire to beat her to death with a hammer.

Actually I suppose my next of kin would be handling that because I would be either in ITU as a result of failure to rescue before the problem got to big...or I would be in the morgue. If my nice caring but not so bright nurse doesn't catch onto my deterioration in condition who will? Anyone who is an RN will find himself alone with a large group of patients and no back up other than untrained carers. The carers won't catch onto my change in condition unless it is blatantly obvious. When it is blatantly obvious it is too late. This is why the nurses need to stay on task with assessments, labs etc. The docs are NOT around to do it, they won't do it and the nurse will take the heat over any failure to rescue screw ups. This is real life not television where the docs are always around the patients and the nurse is just their assisting. That is not real life.

I swear to god that if I , as a patient, caught my RN making tea and making beds rather than dealing with the things that the carers cannot help her with I would be on her ass like flies to shit. I want to live. So should you. The older trained nurses we have now have been around the block about a 1000 time and done a lot of continuing education. They certainly know what they are doing. Don't worry about them. What I am afraid of is a 19 year old here in 2009 who wants to be a nurse getting trained like they did in 1972 and then getting thrown onto the wards in the current situation.

Now that I said all that about dying and needing intelligent nurses let me explain why I think that the all degree qualification for nurses rule is stupid and pointless.

Management does not actually want to staff the wards with trained nurses. On any given shift the majority of staff are untrained carers who do not understand your diagnosis, history, complications, the way your symptoms present and your drugs. The knowledge of all these things is extremely important to nurse a patient properly.

Currently, most of our actual nurses are NOT degree trained. There are 3 kinds of nurses. There are the ones that trained long ago under the old system (most of our current nurses fit into this group), there are nurses who trained in 3 years at uni and obtained a diploma, and there are nurses who trained in 3 years and got a degree (the latter is the smallest group).

I have a degree, my ward sister has a diploma. We are both RN's. We will rarely ever work together because of management. They are dicks. When I am on duty I have a large number of patients with only carers to help and when she is on duty she is also in that situation. They won't ever pay for any more than one RN to be on duty for the same large number of patients whether that RN is old fashioned trained or university trained. Management only wants to hire untrained carers and they want to have as few actual nurses as they can get away with.

This is why nursing care is so bad and a degree won't mean much if they are going to continue to staff the wards in this manner. I want my nurse to be smart, but if she is on her own with 15 patients we are both fucked.

It wasn't too posh to wash registered nurses who wanted these untrained carers brought in to the hospitals. Registered nurses are left with no choice but to delegate all basic care to untrained people. We hate this. It screws things up for me. It screws things up for the patients.

Hope that your nurse is smart enough to get a degree, and hope that she has a manageable number of patients so that she can stay on top of basic care as well as everything else. This is what the nurses want. It is all linked. When this becomes the norm staffing wise, nursing care in our hospitals will improve. Until then, no expensive quick fix band aid will succeed.

Monday, 2 November 2009


It's not all bad. There is that .1% of the time that my job is great.

We lucked out times two the other day. First of all we had 3 staff nurses on duty. Usually that would not be enough. But something else happened that was lucky.

The same random force that can throw all critically patients at you when you are more short staffed than usual can also throw all stable patients at you when you are well staffed.

Actually there was a third lucky thing that happened. The bed manager will usually float a nurse away to another unit if we have more than 2 on duty. But she didn't on this day.

Only two people were on IV meds. No one was acutely ill.

Since there were three staff nurses we decided to put one staff nurse for each group of 14 patients with yours truly in charge and coordinating.

This allowed the staff nurses to get on with the care uninterrupted while I sorted the doctors rounds, the phone calls and intercepted any interruptions before they got to the primary nurses. I answered call bells, assisted the HCA's and made sure that the primary staff nurses were left alone to concentrate on their drugs and the rest of their job. I got their insulins and IV's out of the way for them to save them time. I helped the HCA's with daily care.

I babysat a confused and wandering patient to keep her from escaping to the motorway on foot and half naked yet again. The previous day when there were only 2 staff nurses on it took them until 11:30 AM to get all the 8 AM meds out. On this day because I was there to intercept interrutpions and deal with problems they were done at 09:15 AM.

When our main consultant showed up for his round I approached him, introduced myself as the nurse in charge and told him that I would be attending the ward round for the whole ward and I knew all the patients very well. I had done two night shifts recently and had time to read all the notes etc. He looked surprised. I explained that I was an extra nurse today so we are coping well, and that there would be two staff nurses on the ward attending the patients while I was on the round (which takes 1.5 hours). He was really pleased.

I like going on the ward rounds. It's easy to trail after the docs and answer questions and take notes. I won't even consider attending if it means I have to abandon my patients for hours without having another RN keeping on top of their care. That is just hasking to get hauled before the NMC. I always learn a lot from ward rounds and it helps me get a better handle of what is going on.

Not only did we get everything done but we got it all done well. The patients were happy and the next day a relative gave us a beautiful thank you later. We even had lunch midway through the shift. That was cool.

Just one extra staff nurse and lower acuity allowed for this!

We have approached management asking if we can always have a senior nurse in charge and coordinating every shift just for this reason. Two words: Shot down.
But I will enjoy these rare days when they occur. On these days I am glad that I am a nurse.