One for the road

So much harm, hurt, distress, grief. So much death, so much dying.  It’s hard to know what to write or whether to write at all.  I’ve been thinking about things, and wondering, and sometimes it helps me to get these thoughts out of my head and on paper (screen).  I said I’d put this blog to bed just a few short weeks ago. But sometimes, I have to write.

Over the weekend a few things have been running around in my head and they make me sorrowful but they also provide me with an opportunity to reflect and try to understand.

The old trope of  nurse and doctor as superhero/heroine and angelic special being is alive and well.  It is the overriding narrative of politicians and in all media, together with war metaphors and notions of fighting, of winning and losing.  I’ve been wondering about the pressure this puts on health care workers.  Being constantly heralded as superheroic and/or angelic with all the connotations of extraordinary capability that this carries is a substantial conscious, and subconscious, burden to bear.

In other emergency circumstances, in times of short-term exceptional response – the act of terrorism, the unusually large road traffic accident, the major incident of whatever type – the heroic/angelic descriptor sits more lightly.  A few hours, a few days, most people are treated, set on a pathway to recovery, and the sudden pressures are lifted and life goes back to normal.  Angel or hero for a few days may even feel appropriate and rewarding.

But now? When it ceases to be an ‘incident’ and becomes a new way of living, of working, of being at work?  The only predictability is that more will come.  Hard to see an end in sight. No intervention followed by prompt improvement. No ‘heavy’ days and ‘light’ days, just the relentless file of patient after patient, many who cannot be helped, the isolation, the deaths, the gentle handling of distraught and remote relatives.  The overwhelming numbers and the overwhelming shock.  No-one who ever entered medical or nurse training ever conceived that they would be required to handle this.  Coping mechanisms become fragile, incomprehensible levels of stress become internalised and nailed down in order to carry on. To be the hero/heroine, the angel of expectations.  The pressure must be unbearable.

On top of these come the avoidable things – confusing information, rapid preparation with little time to think through, false promises, inadequate protection for many, inconsistent leadership, frustration with what is meant to be the support system.  And as the days go by, increasing fear.  Fear for themselves, their families and loved ones, their colleagues.  Frustration with a lagging support system becomes anger.  Fear and anger – it’s a losing combination in terms of mental health and wellbeing.

So, it’s small wonder that we see people occasionally kick out.  Under these circumstances being heroic and angelic is time-limited, it’s impossible to sustain every moment of every day.  So, sometimes what might be seen as a ‘safe’ target for that fear and anger might be attacked.  Politicians are a pretty safe target, and often deserving of the opprobrium and scathing comments.  Sometimes those who don’t deserve it feel the heat of people’s anger.  Maybe a boss, or a leader of some sort hits a bad moment and the response is unforgiving.  On the basis of a perceived slight, a real or imagined sense of unfairness, bad timing, whatever it is  – the responses are fast and fierce.

There is small comfort for anyone involved in this crisis.  Everyday on my social media feed I see the ravaged faces, I hear the frustration, I see the anger.  But I also see the compassion, the endless patience, the strength of commitment to doing the best job possible whatever the odds.  No heroes.  No angels.  No heroines.  No Superhuman beings.  Ordinary people in extraordinary circumstances doing extraordinary things.  Whatever their role, whatever their level.  And sometimes being fallible and sometimes being less than kind in their comments.  In other words – being human after all.

Time’s up!

Dear all,

I’ve made a decision to stop posting on the Blogs on Nursing site.  I wrote a little while agothat I was struggling to write about nursing and I think it’s a good time to stop. I haven’t wrapped up my identity with the profession for more than 30 years and so I don’t  do this with any sense of loss or sadness.  I no longer have the motivation or the interest to produce a regular commentary and I surely don’t need any more chores!

Thank you to everyone who has read and engaged.  If you want to continue to engage with me on a more personal level then do try my other blog ‘The Optimistic Gardener’ where I write about all things garden and growing, wildlife and, of course, the knitting.

I shall delete the blog at the weekend.  I may leave the content available, I’ll make that decision later.

Hope to see some of you via‘The Optimistic Gardener’.  With every good wish,

June

We all love a list…

December and January is the time of the year when the lists start appearing – Sports Personality, Unsung Heroes, Deaths, Honours etc. and who can deny the frisson of looking down an appropriate list for someone we might know?  And the world of healthcare is no exception.  Recently we saw the The Health Service Journal’s (HSJ) list of the most influential people in the NHS – those people who hold the power and influence tend to be pretty predictable – politicians and senior managers, heads of organisations, members of the medical profession – probably largely unknown and unseen by the general public.  Definitions of ‘powerful’, ‘influential’ and ‘outstanding’ are entirely dependant upon context, who’s doing the judging, and the interpretation of criteria by the collection of judges.  They’re interesting, but not all that meaningful in the scheme of things.  One thing is notable though, we rarely see nurses on these lists.  On the HSJ list I think there was one out of a 100 (I’m sure someone will correct me if I’m wrong).  Are they really not there? Or are they not looked for?  I’m sure if judging panels included more nurses then we might see the number go up.

So, what if a few nurses who know lots of other nurses got together to try to find a bit of balance?  Not a blingy award, or a sycophantic parade, just nurses nominating other nurses for their outstanding work in nursing practice, education or research, influence on care, potential for the future; whether they are newly qualified or have been around a while.  A list of quietly outstanding nurses who deserve recognition.  Sounds good to me.  In fact it sounded good to a group of us.  Do you want to see a list of Outstanding Nurses put forward by the nurses who know and trust them?  Not a list in order of ‘outstanding-ness’ (how ridiculous would that be?), but a list of 100 nurses who are all equally outstanding in their own way and in their own field.  It’s coming to a Twitter feed near you, very soon.  And to this blog afterwards.

Screenshot 2018-12-30 at 11.45.25

 

Reflecting on Revalidation…

Who would have thought that applying for revalidation with the NMC could be such a uniquely rewarding and affecting experience?  I certainly didn’t.  I thought it would be a chore.  In fact, I wasn’t even sure that I wanted to bother.  I’d heard about lots of older nurses choosing to ‘lapse’ rather than revalidate, although of course I don’t know the reasons for their decisions.  Maybe they thought it would be too onerous, too time-consuming, too threatening even.  Or maybe some of them had had enough of the pressurised life that today’s clinical nursing is and the thought of revalidation requirements couldn’t compete with retirement or getting a different job?

I first registered as a Nurse in 1976.  This November will mark 42 years continuously on the Nursing register, and if I want to stay on it I need to revalidate with the NMC, and I must admit – some of the above thoughts passed through my mind too.

Since revalidation started, I’ve been keeping a note of information I would need, but I haven’t been completely convinced that I would do it.  I read the NMC’s guidance (over and over), and in the end I thought I would fill in the documentation and then make a decision whether to revalidate or lapse.  Documenting relevant practice hours, professional development and feedback was straightforward.  I had made notes of several reflections on events over time, and it was just a case of tidying these and transferring them onto the ‘reflective logs’.

Almost immediately I was struck by how much additional reflection I did as I wrote them up onto the formal documentation.  Filling in the paperwork was so much more than that simple transfer of information; it became a major reflective activity in itself.  Even though I had collected the instances and drafted the logs previously, it wasn’t really until I came to write them up more formally that I really reflected deeply on all of the issues collectively as well as seperately.  So much so that I chose the revalidation process itself as one of my reflective events.

It was interesting to see the issues that I had chosen to use.  They were very similar – communication, working with others, education, influencing others – all deeply significant to me as the main areas of my professional practice as a nurse.  Looking back at my previous notes gave me another opportunity to reflect, often bringing other useful points to mind that had arisen much later on in the validation period.  I saw how distance and re-reflection can bring a deeper consideration of issues, often with more perspective than immediately after an event.  In addition to that, the opportunity to reflect again in discussion with someone else meant that my ‘confirmer’ and I had a great conversation about how some of my reflections resonated with her and helped her reflect too, so we were both learning something.

Having been through the process once I shall be much more aware of events that could be part of the next cycle.  That will mean I am more organised about noting significant learning points from my practice and keeping a good contemporaneous record so that when revalidation comes around again I will be less anxious.  One of the reasons I wasn’t sure that I would revalidate this time was because I’m no longer traditionally employed and I thought that would be a disadvantage – it’s absolutely not.  In fact, one of the most satisfying parts of revalidation is the way the process has reminded and reassured me that I am still operating as a professional Registered Nurse in my particular field and context and that my registration is a crucial part of that.

That deep reflection and aggregation of different reflections has been an affecting experience, and one that I hope others will go through.  I’d like to suggest that the NMC finds ways of sharing reflections from revalidation for others to learn from.  For me, this revalidation has been about effective practice, safe practice, prioritising people and promoting professionalism through my own actions and my interactions with others.  It has been so much more than a paper ‘exercise’.  It has been a revalidation, in every sense of the word.

 

Calling prospective RCN Council candidates…

My last blog (scroll down) was in the immediate aftermath of the RCN ‘no confidence’ vote.  Council had retired to consider its next actions and I reflected on what had led me to agree with the vote.  Last week Council announced that they would be standing down (with some caveats), and a new Council would be elected as soon as practically possible.  There was a little flurry of media activity and then, in the wider world at least, life continued.

Most of the media I’ve seen has concentrated on the nurses’ pay deal as the reason for the vote of ‘no confidence’ in the leadership of the RCN.  Whilst the pay deal was doubtless the trigger for the vote, many people (myself included) came down on the ‘no confidence’ side because of a much broader dissatisfaction with the leadership of nursing’s professional organisation.  As candidates begin to put themselves forward for the ‘new’ Council, I’d like them to pay attention to the reasons why I (and others) voted for change.  I have summarised those reasons below, and I would like to see Council candidates, whichever ‘constituency’ puts them forward, at least recognise these and commit to addressing them in their election statements. They include:

  • a perceived diminishing of the RCN’s function as a professional body e.g. it doesn’t do enough informing/debating the wider issues facing the profession, protecting and championing the role of the Registered Nurse, engaging with the mainstream media on issues other than union representation and terms and conditions
  • failure to engage its wider membership – some 400,000 members – illustrated by the very low turnout for elections and other important votes over a long period of time. Less than 4% for the no confidence vote and often less than that for elections to governance groups
  • an organisational structure that is modelled on an out-dated trade union model of ‘branches’ and ‘reps’ that many members find off-putting, not reflecting modern multiple channels of engagement and not adequately content-driven
  • perceived conflicts of interest, e.g. unable to champion the primacy of the Registered Nurse because it also counts health care assistants/nursing support staff among its members; difficulty in promoting the development of the profession as a whole because it has a major function to protect the interests of individuals – and what may be good for the profession in the long-term may not seem good for individuals in the short-term.

These issues are important to members who see nursing in an increasingly challenging position – inadequate articulation of the unique value of the Registered Nurse, dilution of the workforce, antipathy towards higher education for nurses, an image that is stubbornly resistant to the recognition of the changes and developments in the modern profession, a disaffected workforce creating retention problems for employers and safety issues for patients – and our professional body failing to effectively challenge and articulate these.  

A successful ‘no confidence’ vote was an historic moment in the life of the College, and now that the dust has settled a little, meaningful dialogue with members is needed to move forward.  The feelings that led to the vote won’t be satisfied by a new Council – elected through the same mechanisms as the old, and subject to the same modus operandi – smiling out of headshots and making aspirational statements.   As more and more nurses have graduate education and post-graduate thinking skills, they will not be satisfied with old thinking and old ways.  They’ve been taught to challenge, to push beyond the status quo, to learn & act on evidence.  They’re used to multi-channel, content-driven communications.  They want to pick & choose, not take what they’re given.  Traditional thinking, traditional expectations and traditional organisations are not going to cut it for them – inside or outside the profession.  They are looking for a ‘voice’, and not finding it where they should.

So, prospective candidates – I’d like to hear some thoughts on how you might tackle the bullet points above.  And if it sounds feasible, and creative, and responsive, then maybe, just maybe, someone will be elected on a turnout bigger than 3.47%.

Times of trouble…

Today the Royal College of Nursing held an Extraordinary General Meeting (EGM).  You can read about it here and you can also read both sides of the argument from a link on the same page.  A recording of the debate will be available shortly on the RCN website.  I couldn’t go to the EGM but I did watch it streamed live.  I’ve also been openly supportive of the resolution that was proposed:

“We have no confidence in the current leadership of the Royal College of Nursing and call on Council to stand down”.

Briefly, the resolution was sparked by the feelings of disappointment and anger when the pay deal that the RCN negotiated for its members wasn’t quite what they had been led to believe. The furore resulted in the Chief Executive/General Secretary standing down from her post and the College instigating an independent review of what had happened to cause such a breakdown in communication and understanding.  You can read that review here too.  Some people thought this should be enough.  Some didn’t and felt that accountability for whatever happened was likely to be more widespread than one individual.  Hence the resolution.

Today the vote on the resolution was held and the results were:

For the resolution: 11,156

Against the resolution: 3,124

So the resolution was carried and the Council should stand down.

I voted in agreement with the resolution.  I’ve been open about my views on the subject on social media.  I’ve also been open about my broader concerns about the College.  For example, it’s my view that the College does less than it could do to develop and support the profession as an entity.  It is a Trade Union and much of what we hear from it is related to that part of the College’s business – representation, terms and conditions, supporting individuals.  The structure of the College follows a Trade Union model.  The language of reps, and branches, and elections and votes turns me off.  I think it turns a lot of people off – see below for what I think is some evidence of that.

The communication to members is through these structures and from what I hear from friends and colleagues, rarely gets beyond those who attend branch meetings, or who are involved ‘reps’ or union activists.  In today’s nursing world sophisticated communication strategies that use multiple channels are needed.  Keeping the noticeboard up to date is really not going to cut it.  And communications should be easily two-way.  I don’t see that.  Finding agendas and minutes is a struggle.  In fact, to date I haven’t found any minutes, just meeting ‘reports’ – sanitized and reduced notes without even the members present being recorded.  I shouldn’t have to search to find information that I have a right to see.  It’s not transparent.  These are symptoms of a management that want to keep knowledge as power.  Or that’s what it says to me.  Others may find it perfectly acceptable.

But back to the vote.  The RCN has more than 400,000 members.  That’s a lot of people.  Do you know how many members voted in this really important vote on the very essence of the RCN’s practices?  Less than 4%.  In fact 3.74%.  This isn’t unusual in RCN elections. In the recent elections for the Professional Nursing Committee – the Committee that is supposed to reassure members that the College is more than a Trade Union – the committee members were elected on about the same turnout, or less in some cases.   It also appeared that getting the right strategic skills and experiences brought to that Committee at a crucial point for the College were secondary to following a Trade Union election model; and that employment, age, and geographical location were more important.  It was disappointing.  And it said to me, that nothing was changing here.  New committee, old thinking.  Less than 4% turnout for important elections and votes.  An organisation that can’t engage, or even interest, more than 4% of its membership in these fundamental activities is an organisation that is failing its members.   What I heard from the EGM today was the RCN promising to reach out to its members.  All well and good, but first, it needs to take a long, hard look into itself.

I’ve been a full member of the RCN for 42 years.  45 years if you count my student days and  I want this organisation to work for me and for others like me.  These days, I work for myself.  It’s very liberating.  But I still want to belong to a professional body that champions my profession.  That gets itself into the mainstream media.  That is a ‘voice’.  For example, I expected at least a blog from the RCN on the implications for the profession and it’s value to national policy-making when the CNO stepped down into a part Regional Nurse role.  I would have liked to see an exploration from the RCN on the background to the CEO of the NMC standing down and a broader discussion on the regulator and how it protects the public and also protects the profession from itself.  I expected outrage that Trainee Nursing Associates won’t need to be supernumerary when they are supposedly learning in practice.  But the issue that exercises me more than any other – is the absence of a strong, authoritative RCN voice drawing attention to the dangers of diluting the workforce.  The danger of undermining the contribution to patient safety of the Registered Nurse.  Why aren’t they quoting chapter and verse of the research on RNs and safety/mortality/recovery, and getting that talked about outside of the profession?  I don’t understand how the College can stand square behind the primacy of the Registered Nurse when it also has an obligation to promote the roles of members who are not Registered Nurses.  I think that’s a serious conflict of interest.  And these things are why I got involved in this vote.  I thought – hoped – it was a catalyst for a whole range of dissatisfactions to be raised; and some of them were raised at the EGM.  And I’m raising them again here – for what it’s worth.

No CNO, no CEO of the NMC, no CEO of the RCN, and RCN Council vilified by (some of) its ordinary members.  Some would say this means that at a really troubling time for the profession – dilution of the workforce, failure to regulate advanced practice, substitution of RNs, antipathy towards higher education for nurses – there is no visible leadership.  I disagree – because for quite a while now I haven’t looked to these roles for leadership.  They are too embedded in Govt, employers and established systems to ever take an independent stand, to speak against the status quo, to be awkward.  I look for other voices, other influencers, other opinion leaders, independent thinkers, independent minds.  A professional body, more than anything needs independence.  Independence from Govt, from party politics, from employers, from factions.

But on the other hand, I really want a renewed RCN to be a voice and to show leadership for the profession as an entity, not just seeming to represent a group of workers with employers, or fighting the government, no matter what political shade it is.   My vision for that renewal is entirely predictable, I want the trade union activity and professional activity to be separate – completely separate.  So that the professional body can champion the profession, without fear or favour.  Because sometimes, what might be in the best interests of the profession in the long-term, may not be in the best interests of individual professionals in the short-term (another significant conflict of interest in my eyes).

So, stream of consciousness over.  As usual, this is meant to encourage you to think a bit harder about this, a bit further than the vote of no confidence, and the pay deal.  I’m not asking you to agree with me, and I’m not saying I’m right or that my take is the only one.  I’m just putting my worries out there.  Catharsis.  And, I hope, stimulation.

Every picture tells a story…

I am never stuck for a blog subject – in fact, sometimes it can be difficult to choose between competing possibilities.  And today is no exception.  Do I write about the shambles surrounding the miscommunication of the recent pay award?  Do I write about Gosport and the way that an awful lot of nurses thought it was OK to say (and do) nothing whilst inappropriate medication regimes were prescribed?  Do I write about the issues facing the nursing regulator?  So many blogs, so little time.  Last time I wrote about nostalgia and the dangers of thinking that the past is a better place.  And I am minded to continue that theme today because this morning something happened that compellingly illustrated the meaning behind my last blog – that ‘nostalgia is a seductive liar’. 

Whenever I, and others, talk about what we call ‘modern nursing’ i.e. evidence-based interventions, Bachelors degree entry-level, autonomous practice, acceptance of accountability, being patient-centric, professionalism with a big P etc. there is an instant response from far too many people (including nurses), denying the need for all this unnecessary over-thinking and calling for a return to the days when ‘nurses did the real work at the bedside and patients were properly cared for’.   It has become depressingly familiar.  The rose-tinted specs go on, the self-preservation and lack of insight appears, and those who defend their own level of training/education as the best there has ever been promote their vision of the past as a credible way to handle the future.  Sadly, some of this even finds its way into policy making.  As I said, it’s depressing.

So, this morning when the video below appeared on my Twitter feed, shared by Liz Anderson who tweets @nutritionlizA, I thought it might illustrate some points, although I wonder how many of those who need to read this blog, will actually see it.  I suspect I am preaching to the converted.

I have first hand experience of this sort of nursing.  I spent many hours as a student nurse in the early seventies working with Staff Nurses and doing exactly this.  In elderly care environments and also in more acute environments, the principles were often the same – get the jobs done.  And when you watch you can see that there is care here – these patients are bathed, and dressed and undressed.  They are positioned in bed and turned.  Their hair is combed, their bed linen is fresh.  Their environment is clean and tidy.  I can hear some people saying ‘Yes, and that’s how we need to be now. Those patients were really cared for’.

And look at the nurses.  Busy and purposeful.  Tidy and their rank obvious.  Brisk.  Getting the job done.  All patients washed, clean, tidy and neatly in bed.  All boxes ticked.  ‘All care given’ – remember that? Written in the Kardex?  ‘All care given’.

But, oh, those women.  Naked in a public place.  Covered as an afterthought by a towel.  In bed though it is broad daylight.  Tucked up and tidy with covers right up to their chin.  No conversation.  No information.  No choices.  No distraction.  No entertainment.  No interaction.  No interest.  And look at their empty faces, the weary eyes, the resignation, the waiting, the sadness.

I know that this is not how we expect things to be now.  We have moved far away from the rote completion of tasks and those in our care are treated as individuals with all the involvement and interaction and choices that means.  Getting the jobs done is not at the heart of our care any more, is it?  Seeing the individual, understanding what those facial expressions or that body language and those clinical signs mean, and responding to them appropriately and thoughtfully, drawing on our education and experience to make changes, to tailor interventions, to improve lives – these are the actions we would expect now.   How differently those women could expect to be treated, nursed, today.

The difference, the biggest, most obvious difference in my opinion, between the nurses in that video and today’s nurses – is in the education of Registered Nurses.  Rigorous academic teaching of the developments in nursing and in medicine, a greater  understanding of the elements that help to keep people in our care happy, healthy and safe and comfortable, and the clever translation of that into appropriate intervention.  A complete change of approach from ‘getting the tasks done’ – the baths, the rounds, the teeth, the hospital corners and the turned under counterpane (a signal action of the 1970s nurse) – to seeing the whole person and understanding what is going on in their bodies, and their minds,  and how we can help them.  Having the intellectual capacity and intellectual training to be able to access a huge knowledge base, sift what is best in any given situation based on the evidence, and apply it confidently and with exquisite individual finesse.  It has been a transformation.  Mostly.

It makes me very nervous when I see shifts in the way that care is led and organised that seem to promote the task above the knowledge; the ‘basket of skills’ rather than a depth of education that enables the intervention to be chosen and tailored, modified and improved upon.  It reminds me of these times.  In this video the tasks were done.  The jobs completed.  I’m sure any checklists were filled in.  But it looked pretty grim to me.  Valuing the rote performance of task is backward and dangerous.  And it is still around us.  There are places where the thinking (or lack thereof) of some can be frighteningly similar to that video.  I blogged about my experience of the same sort of thing in a different context during my mother’s last weeks in a hospital, just two years ago.

I cried when I watched that video.  I cried for those women, and for the ignorance of the past.  What makes the difference between that video and today? Education and the application of knowledge in every moment of practice.  The valuing of education as the route to excellence and safety in care.  Let’s not start forgetting it now, for pity’s sake.