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Grumbling Appendix: an announcement

Dear Friends,

Grumbling Appendix will never return to blogging about nursing. I do still write though – my current blog, Food Covolution, is an attempt to brighten up the miserable food culture that is currently taking the shine off UK City of Culture 2021. I have also given up writing TV reviews, but my take on GBBO Series 6 Week 3 earned high praise from Dorret.


Thanks to everyone for reading and I hope I have occasionally managed to make people think, even if only a little.

What else did I do wrong?

By Basket Press

Aside from, as per my last post, being over-educated for nursing in the ’80s, or ever depending who you listen to, I was also the wrong gender, what with being male even in mental health (MH) which traditionally has a higher proportion of nurses who are male (see a couple of GA’s recent posts).

I don’t think this was viewed as such an affront as being educated (this is England, with its at best ambivalent attitude to learning) but I still wasn’t right. Please don’t get me wrong: I am not complaining, rather observing and describing.

OK, I have never responded well to “Oh, you’re a male nurse?” “No, I am a nurse who happens to be male: there isn’t a separate part of the register which says male!” But that tends to be outside nursing.

There were then, and still are, problems in being male and accepted as working in a caring role. Even the children of my general nurse sister struggled with the idea of me as a nurse. Acceptance is easier, it seems to me, if there are either higher educational expectations and perceived power and authority (medicine, for example) or more technical, nuts and bolts aspects to the job (physiotherapy or radiography, for example) than in something less well-defined and generally perceived as lower status (nursing for example) and especially than in a branch of nursing which can be even less tangible and of lower perceived status than others. Clichéd, stereotypical views of how one must think and behave as a man seemed to stop many from seeing an actual person: all the exhortations to see patients as whole people go missing when it comes to colleagues.

Allied to this I have rarely completely conformed to local gender stereotypes: throughout school and university I was seen as being unmanly, not a proper male, as I wasn’t a macho dickhead northern male (1970s, remember); I was thought to be gay before I even knew what that is, something which, with weary inevitability, has followed me since, especially once I entered nursing. Again, an inability to see a person, but rather reduce them to a lazy set of preconceptions. Would it have helped if I was gay? Dunno, I probably wouldn’t have conformed to stereotypes of gayness either…

By the by, I was never really a ‘hetty’ either (as a gay friend insisted on calling heterosexuals, as if I was “straight” that meant he was “bent”, which was not how he saw himself), being married but quietly child free by choice, which some seem to take very personally, my existence apparently undermining their decisions.

And then it starts to get a bit meta, as people would make assumptions about what assumptions I would make (the possibility that I would try not to make any assumptions did not compute). This was often around how I supposedly viewed women: I’m male, from northern England, of a certain age, therefore…Wrong! I was brought up by and around women in responsible, senior, professional positions, who exercised authority and power. This was normal for me. My year at grammar school was the first when the two single sex grammars in the town went co-ed; the 6th form was half female and as many females as males went to university. This was normal for me. At university half of my course was female and I spent much time learning about that 1970s wave of feminism. This was also normal for me.

I know that is not usual, but it happened. That was my reality, where I came from.

It was assumed that I would head rapidly up the greasy pole, a combination of assumptions about education and gender. OK, I quite like being in charge, but this isn’t a gender characteristic, more to do with personality as my sister behaves in very similar ways: if push comes to shove we both prefer being the one making decisions and accepting the consequent responsibility, or as my wife described both of us “You two just go into nurse mode whenever anything serious happens!” Neither of us flaps nor panics, we are both calm and decisive people, who don’t scare easily and want things done as quickly and efficiently as possible. Oh, and we don’t suffer fools. At all.

I did not go up the pole particularly quickly (see other posts for details of my difficulties with management), rather following what interested me from the limited range of options.

Then factor in the “You’re male so you can’t possibly work with…” Oh really? At one point or another I have successfully worked with bairns with eating disorders, male and female, depressed bairns, male and female, self-harming bairns, male and female, bairns with gender identity or sexual identity issues and…and…In my experience it is rare for my gender to be a real problem (I have been chosen by a couple of young ladies to be the one to whom they would disclose sexual abuse). Yes, there are certain aspects of care, especially in in-patient settings, where gender of a nurse can matter, but that one cuts both ways. And outside that it is the quality of the working relationship which matters and how one can make that work: I can persuade some very difficult young people, male and female, to talk to me, which has nothing to do with gender and everything to do with personality, approach, skill and experience.

Patients come in all manner of different forms, reflecting our society, why is it still so hard to accept that nurses might? Why is caring seen as the preserve of a limited part of that society? Why do some persist in stereotyping, to the detriment of us all? Whatever happened to open-minds and acceptance?

How did I get here?

By Basket Press

A couple of recent posts here (thank you Florian and GA) made me try a different tack to my usual, more politicised, management-critical one.

I didn’t take a “usual” path into nursing: attended a state grammar school in the ’60s and ’70s; did as ordered and went to university, emerging with a science degree. My mum swore my first word was “Why?” and that my first phrase was “How does it work?” and it was all downhill from there, taking nothing for granted and questioning pretty much everything.

My background includes pit village Methodism with its underlying ethos of public service, and the significant adults in my life did just that: nurses, physios, teachers. The parents of my school mates were similar: teachers, lecturers, doctors. This is what grown ups do it seemed to Junior Basket Press. I gave up the God bits, but still describe myself as culturally Methodist.

An oddity of my upbringing was that I didn’t meet a child my own age until I started school. It took until my early 20s to feel comfortable with people, and consequently I consider making a living talking to people an achievement.

Unfortunately I graduated in 1979 and became a Founder Member of Maggie’s Millions.

The next few years were a mix of dole, trying to convince myself I was a real scientist, dish washing, more dole, and 2 jobs working for environmental charities with youth and school groups.

Then the light dawned: the groups I most enjoyed working with were from schools for blind bairns, those with emotional and behavioural difficulties and other out-of-mainstream provision. I found these groups both more challenging and rewarding than others.

The last of these jobs finished and I was on the dole again. I should note that a previous bit of societal rejection had brought out my under-lying tendency to depression, which I’ve lived and dealt with the rest of my life.

A colleague suggested considering nursing. Luckily, I had a cousin who was a nurse tutor, whose advice I sought. Her sensible suggestion was to find a Nursing Assistant (NA) post in Mental Health (MH) to check out if it was for me.

I hit lucky. Responding to a generic NA job ad at the local MH hospital, I found the adolescent psychiatric in-patient unit was after NAs, preferably with a background working with young people. I interviewed well, referring to how my own difficulties could give me an appreciation of what others might experience. I got the job.
This went well enough for me to successfully apply for nurse training.
And the problems began.

It was obvious very quickly that graduates were unwelcome: I never referred to my degree unless directly asked, but the tutors knew, people in my group knew, and word got around. I found it hard to disguise my tendency to ask questions and challenge any lack of evidence. Assumptions were made about me by people I hadn’t even met, which were all negative (“Wants to be a nursing officer right off” was as polite as it got) . This meant I had to be better than anyone else at straightforward clinical care in order to be taken remotely seriously.

I wasn’t alone in these experiences: the two other graduates training at the same time as me went through this. Indeed it was one of them who advised me that I needed to volunteer for things which folk didn’t like doing, to play along with ward nights out and be better than excellent at day to day stuff to survive,. So I got a reputation as a bit of a smartarse, but one unafraid of hard, dirty tasks, who wouldn’t shirk and gave as good as they got in the black-humoured hospital repartee. It paid off in uniformly good ward reports.

If only it was just at work…All my immediate family, bar the afore-mentioned cousin, took a dim view of me “wasting” or “throwing away” my degree by not just going for nurse training but, even worse, MH nursing. This included two general nurses and two physios…OK, I was the first in the family to go to university and obtain a degree, but everyone else thought it belonged to them and they had a say in how to use it. Fortunately I had learned not to listen to most of my family, which was just as well as it never got any better; there was never any recognition that I was doing something useful and necessary that I was good at.

Apparently it was impossible for a graduate to carry out basic care, because I lacked common sense, was too airy fairy, too bothered about theory, didn’t live in the real world, came from another planet, didn’t speak English, had three heads…And yet the necessity for medics to be graduates wasn’t queried, because…No-one could explain that.

Yes, I questioned what we were told in nursing school, mostly because, when a paper was forthcoming, we were being fed misinformation and mangled statistics. I questioned things on wards. I asked consultants about their reasoning and how they reached a particular judgement. And I was always polite. I need to know why, and if a particular thing is justified and supported by evidence; I won’t just do as I am told.

What I learned from all this was that most medics do not mind sensible questions; nurse tutors didn’t understand statistics and got uncomfortable when questioned; many nurses in big MH hospitals and on my general placement rapidly get set in their ways and don’t like to be challenged, no matter how politely, no managers like being questioned or challenged and take against those who do so. The latter two phenomena made me question myself and nearly drove me out of nursing years ago, but didn’t.

Read some posts on this very blog by younger nurses: how much has changed? Not much, despite the efforts various of us have made over the years, which is very sad.

Hello and Welcome…

Hello and welcome to the new NHS fun games show ‘How Essential Is Your Job‘?! Leaving aside the obvious caveat that if you’ve got time to play it, your job probably isn’t essential, let’s have a peek at some sample questions!

Question 1: A ward has an outbreak of C Diff. Your role is a) assist and comfort soiled patients; b) ensure sufficient staff are available to assist and comfort etc; c) co-ordinate/investigate/monitor/contain; d) draw ward’s attention to overspend on nursing wipes. Question 2: A patient needs to be specialed. Your role is a) act as special b) ensure extra nurse is available to act as special; c) co-ordinate rapid transfer to environment less likely to cause distress; d) inform the ward (by phone, obvs) that a special is unaffordable and will need to be found from within existing resources, goodbye.

Now tot up your scores! Mostly A’s, B’s or C’s – sorry, your job is not essential. You are advised to contact your nearest Job Centre. Mostly D’s – congratulations! Your job has been rated ‘essential’ and is not at risk. How do I know this? Actually, I don’t – but in the absence of any clearer definition of ‘essential’ in Monitor Chief Exec David Bennett’s recent letter to Foundation Trusts (FTs), I think we’re free to assume that for the next few years, saving money will be more important than saving lives.

To be fair, after publishing his letter, in which he warned that ‘almost unprecedented financial challenges’ meant FTs should consider filling vacancies ‘only where essential’, Bennett did backtrack to the extent of issuing a statement saying that ‘this section of the document related to non-clinical staff’. As the esteemed Basket Press OTP observed in a below the line comment on this story, you could be forgiven for thinking Vicky Pollard is in charge of Monitor these days (‘but yes but no but yes but no but yes…’).

But even after this so-called clarification, questions remain. Bennett’s spokesman added that he would be ‘surprised’ if Trusts interpreted the letter as an instruction to stop hiring clinical staff. ‘Surprised’ eh? As a sanction, it’s not really up there with being barred for life from ever darkening the door of public sector employment, is it? I can’t imagine that Finance Directors up and down the land are quaking in their boots about the prospect of making a spokesman feel mild-to-moderate ‘surprise’ when the s*** from the next Mid-Staffs hits the fan.

More worrying still, Mr Mild Mannered Spokesman also declined to elaborate on another of Monitor’s recommendations: that safe staffing guidance should be ‘adopted in a proportionate and appropriate way’. Sorry mate, but what does that even mean? You’ve got the guidelines – you either stick to them or you don’t: it’s that simple. Like the Highway Code, safe staffing guidelines are there to protect everyone, all the time, and not – repeat not – only when it suits. Forgive the bluntness, but this is how people end up dead.

I suppose (if we were desperate) we could always turn to Jeremy Hunt for some leadership. In a Q&A session after a speech delivered at the Kings Fund in July, he said he was against introducing a different safe guard – mandatory minimum staffing levels – because ‘you could have two trusts – one with higher levels of staff who spent “a lot of time filling out forms” and another with lower numbers but with “vastly safer care because they worked out systems and process which means staff can spend 80% of their time on patient contact”’. It’s a completely spurious answer of course. Such wide variations should not even be tolerated, much less used as an excuse. True leadership is about turning ‘the best’ into ‘the norm’.

As others pointed out after the Bennett letter broke, the workload remains the same however many staff are available to do it. So while some staff may look ‘non-essential’, all that’s achieved by removing them is reassignment of their work to those who remain. And historically, this has usually meant ‘the nurses can do it’ – after all, they’re available 24/7 and although there might be muttering before home time, they rarely make any real trouble.

NHS nursing is facing a perfect storm. With work on safe staffing apparently sidelined, plus the prospect that we will increasingly be asked to shoulder the work of ‘non-essential’ others, Jeremy Hunt is effectively asking the question ‘what is nursing?’. Which of the following then, is most likely to be his answer?: a) a confident, independent therapy, essential for the delivery of collaborative health care; b) the workhorses of the NHS, there to keep their heads down and get on with the job; c) whatever politicians need it to be at the time; d) form-fillers – didn’t we classify that as non- essential?

You keep using that word…

By Basket Press

Ho hum…Another day, another piece of “official advice” in which David Bennett, the chief executive of Monitor, tells foundation trusts to ensure that staff vacancies are filled “only where essential”, but without offering any advice as to what essential actually means…

The excuse is the usual: save money, y’know, the same reason we have all heard for years why posts are frozen, recruitment is suspended until the next financial year, yada, yada, blah, blah. As David Byrne so perspicaciously put it, same as it ever was.

I don’t know about you, but I would expect a man who in 2011 was the highest paid employee of the NHS in England and was described by the Health Service Journal as the 8th most powerful person in the English NHS to be capable of giving some clearer guidance here. A man who spent 20 years dispensing advice to others about how to run organisations when he worked for McKinsey (yes, that McKinsey, the mega firm of management consultants who seem to run the world) and earned a salary well in excess of what any of us mere nurses are ever likely to see for doing so. But apparently he can’t. Which makes me wonder what he’s there for.

Ever since the first Griffiths report back in the ’80s gave us general management and started the cult of managerialism we have been told that managers should be allowed to manage, and yet here we have one of the top, most highly paid NHS managers side-stepping that very responsibility and passing it on to someone else.

Anyway, “essential”: my handy copy of Chambers says things like “necessary to the existence of a thing” or “indispensable or important to the highest degree”. So how does this translate into NHS terms?

I believe it is time to break out The Basket Press Three Phase Model of Organisational Structure (patent pending), which can be applied to most organisations I’ve come across.

Phase One consists of those staff who carry out the core function of the organisation. In the NHS this means clinicians, nurses, doctors, physios, psychologists, OTs and so on and so forth. That’s us, the ones who do the direct health bits. Without Phase One the organisation might as well pack up.

Phase Two is those staff without whom we don’t function, which is secretaries, receptionists, payroll, porters, pharmacists, lab staff various, radiographers (OK you can make an argument that some of these might go into Phase One, but bear with me as it doesn’t change my overall point), catering, technicians various, and apologies to any I have missed. Without Phase Two we can pretty much pack up also.

Phase Three is the staff we can do without for significant periods of time, if they are needed at all. This brings us to pretty much all management and HR, non-exec board members and the like. If we lose some of these do you actually notice? We can certainly carry on for quite some time, unlike the loss of the other 2 phases.

Now before I am accused of being anti-management, which I’m not really, I just think what we have is over-rated , let me tell you a story or two to expand on this.

In my last job there were regular and frequent times when we were down on clinical and/or admin staff and the rest of us and the patients knew about it every single time: not enough staff for clinics; waiting times going up; prescriptions not written; assessments taking longer to complete, if they could be completed at all; longer for diagnoses to be made; longer times between appointments; inability to respond to crises; letters not sent; appointments not arranged; reports not compiled; phones not answered. Mostly posts were kept empty, as mentioned above, for financial rather than functional reasons, for as long as possible, which just compounded the difficulties created.

And yet, on more than one occasion, we went for up to nine months without a service manager: none of the patients noticed; clinical work happened as it should; the service carried on running; a couple of us signed time sheets and expenses forms; the sky didn’t fall in.

The same was true when the trust did not have a permanent chief exec for months, when there were vacancies for senior HR bods, when we were without a couple of non-exec board members: no-one noticed; patients were still seen; everyone else just got on and delivered the services. And when those posts were filled we still didn’t notice, patients were still seen, only a name on the letter head changed…I can’t remember when I last actually met a chief exec and have certainly never met a non-exec board member and this is after over a decade as a senior nurse.

In another job we had one of those interminable trust mergers, which meant that for over 6 months there was a management vacuum while everyone above an H-grade (Band 7 in current money) played hunt the desk and hunt the job, no-one was contactable, we never saw them, and yet clinical services went on, patients were seen and the sky remained resolutely over head.

And it is always, but always, thus: I’ve lived through several lifetimes’ worth of mergers and restructurings and reorganisations and whatever they call it this week and patients are always seen, even when Sherlock Holmes, a team of blood hounds and Hawkeye can’t find a manager or anyone else supposedly in authority or in any way running the organisation.

So, perhaps Mr Bennett in his position of great power and authority, with all the undoubted wisdom accumulated from years of telling other people how to do things, might somehow find his way clear to telling us what it is that he considers “essential” to the running of a health service? Pretty please, I’m asking nicely, with cherries on top. Please?

Another Brick in the Wall

A guest blog by Florian Nightingale

So, almost twelve months have passed since I first pulled on my blues and started grafting. It’s been an entertaining (for which read tumultuous) year. I’ve learned a lot and have developed beyond what I ever thought possible, both as a nurse and a person. I will echo some thoughts I had in an earlier blog for Grumbling Appendix: the year has been a bitter sweet one. For this, there are many reasons – I’ll talk more about them in a while.

This first year has been one hell of an experience. It has tested my strength as a person and my desire to stick to my standards and values as a professional. To maintain those standards, and to take myself to exactly where I want to be as a nurse, I’ve had to push myself through a variety of challenges to my motivation. More importantly, I’ve had to make the seemingly simple – but in reality very hard – decision to stick to what I believe nursing to be, and not give in to those other, more anachronistic, voices that I don’t agree with. That has taken considerable moral courage on my part and in some ways on the part of those I know who are of a similar mindset to me.

Those negatives aside, this year has indeed taught me a lot. It most certainly has set me up well for my new job which I start next week. The biggest lessons it has taught me are as follows:

If not me then who?;

Reinforcing my personal integrity to ensure things get done;

A vast amount about the conditions I treat;

We eat our own. We are our own worst enemies.

I think the biggest lesson I’ve learned, and the one that will stay with me more than anything else, is my desire to stick to what I see nursing being. Maintaining my drive over years to come is going to be tricky, and I am considering where I could go if and when I start to get fed up with nursing. This is as a direct result of the final lesion that this year has taught me – and it is an exceptionally sad observation to make of nursing in 2015.

We are our own worst enemies. The least progressive profession and the owners of the most entrenched mindsets. These are holding nursing back from all it can be. From my place in the vanguard of a new generation, I have the opportunity to counter this and ensure that there is a decent atmosphere for nurses of the future. However, I doubt that all the people I trained with are as obstinate and driven as I am. A sad note but probably a prophetic one.

All in all, lots of lessons learned. Not all of them pleasant or enjoyable, but beneficial nonetheless. I move to a new post next week. In some ways this year has set me up well for it. I won’t know how good I am until I get there. There is some trepidation but for the most part I am happy to be moving on. This is for a variety of reasons, foremost among them because it’s what I really want to do and somewhere I can see my career going because I can find my own path, or at least the idealist within me thinks I can.

I leave you probably in a similar place to where I am. Not quite sure about where I’m going, how I feel about it, or, sadly, how much longer I’ll be in nursing for. Good night and good luck! All in all, it was just bricks in the wall.

Do not adjust your (mind)set

“The type of nurse I am” said Caroline – a ward manager who combined exceptional academic achievement with exceptionally compassionate care – “is because of the person I am”. Caroline, it should be noted, is the possessor of what episode two of Who Wants to be a Nurse?, BBC Radio 4’s short series on the profession, rather sniffily described as a ‘portfolio of degrees’ and is currently studying for her second Master’s. But for all that, her definition of a ‘good nurse’ still rested primarily on an extension of a ‘good’ personality. As a statement, it was typical of a programme that seemed determined to undermine the value of degree nursing.

The scepticism was evident from the get-go. Emergency Nurse Practitioner Ruth was shown independently (and very capably) treating patients whose injuries ranged from eye damage to ruptured Achilles tendon. Asked about the additional qualification she had gained, she told interviewer Jenny Clayton that “it was very practical, it was very hands-on, which is entirely the way I like to learn, and the way my brain works”. Caroline’s almost permanent engagement in academic study was, by contrast, presented as a little more than a hobby, an end in itself with limited relevance to day-to-day work.

In some ways of course, this is a completely accurate picture. On the subject of pay, Caroline told Clayton that “I don’t get any extra pay for the training that I’ve done”. Her rationale for all the extra study was rather ‘to gain much more knowledge and experience in the areas that I’m interested in’ – again making it sound more like a slightly self-indulgent personal quest than something that could actually benefit patients.

Throughout the whole programme, an underlying assumption of a rigid duality between ‘compassionate’ and ‘academic’ was constantly re-enforced. By way of explaining the nature of her interest to the anonymous Achilles tendon patient in ED, Clayton informed him that ‘there’s a whole discussion in this country about nurses being too academic and not compassionate enough’ (you can’t be both, evidently). She went on to express surprise that a nurse as highly-educated as Caroline would still take on the job of finding a temporary home for a patient’s cat.

But the problem here perhaps lies more with the perception of what an ‘educated person’ should be like. An educated person, on this reading, doesn’t concern themselves with ‘menial’ tasks. An educated person is, perhaps, more concerned with the generalities of running a smooth operation than with the specifics of a particular individual’s distress.

Nursing needs to challenge these preconceptions. Why on earth shouldn’t an educated person assess that anxiety about a much-loved pet was putting a patient under avoidable strain, and take action to alleviate it? If holistic, patient-centred care is about anything, surely it is about recognising as a priority whatever is important to the patient?

In Caroline, we caught a glimpse of a nurse who seamlessly combined the academic and the hands-on strands of nursing into a single very effective whole. In spite of all her academic prowess, she told Clayton that “I’m probably known on the ward as the person that baths the most patients, because I think that’s the time you have the opportunity to find out how the patient is”. Clayton describes as ‘interesting’ her combination of ‘the highly technical and academic and the very compassionate’. But is it really?

Educated nurses, provided they are given the time and the support, can be all these things, and why shouldn’t they be? Unfortunately, Who Wants to be a Nurse? was entirely constructed on the premise that nursing is instinctive – as when Ruth was heard saying that she has a ‘sixth sense’ and can ‘just look at a patient and know whether they’re ill or not ill’. Academic education is nice for those who want it, but not essential. Underlying this was the assumption that an educated person would not want to be a nurse because traditionally, education is supposed to equip you for an escape from the messy stuff in life. I found this disappointing. I had hoped for something better from Radio 4.

The light at the end of the funnel

I wonder if Jeremy Hunt tuned in to Who wants to be a nurse?, BBC Radio 4’s new two-part investigation of the inner workings of the profession. ‘Aha!’ he might have rationalised it to himself. ‘One of the contestants might phone a friend, and the friend might come up with the solution to the whole nursing recruitment crisis thingy! I cannot afford to miss!’.

The half-hour broadcast explored the experiences of four student nurses – one male, three female – from the University of Essex. Background information was pretty sketchy – we learned little about their various employment and education histories or motivation to enter nursing. All appeared to be twenty-somethings, two lived with their parents, one was a single mother and all were studying adult branch. The answer to the title question seemed to be that most aspirant nurses continue to be drawn from the traditional pool of young(ish) white women. Sorry, Jeremy.

But stick with it though, because it turns out that despite ducking its own opening question, the programme went on to pose – and attempt to answer – a number of others, all of them very pertinent. In the closing minutes, presenter Jenny Clayton drew the various threads together by asking a new question: what do we want our nurses to be?

The phrasing here is very loaded of course. Implicit within it is an assumption that the nature of nursing is a matter to be decided on as much by public agreement as by debate within nursing itself. Nurses, or so the subtext reads, do not merit having the power to set their own terms of reference. In this context, it was telling that both Peter and Charlee had turned to service users for insights into how a ‘good nurse’ behaves. However warm and cosy it might look though, the idea that nursing philosophy is really dictated by service users is a pretty sizeable red herring.

All the students spoke about the high pressure and low morale they have encountered on placement. Peter, in an evocative turn of phrase, called it the ‘funnel of negativity’. But much of this is the result of the dead hand of political and economic priorities. It is the target culture and chronic underfunding that are largely responsible for removing ward nurses from the satisfactions of the bedside and turning them into what are effectively throughput managers and risk assessors. No wonder we no longer know who we are.

And it was this issue, the uncertainty and lack of definition around the nursing role, that was the real heart of the programme. Peter summed it up when he said ‘Nobody really knows what a nurse is. Are they senior practitioner, are they the carer, are they someone that’s gonna prescribe drugs, are they gonna diagnose a stroke – as nurses do – and give the thrombolysis to cure the stroke..? What’s their role? I mean, it’s sort of lost in this world of training’.

Training, or education, is of course the silent fulcrum around which the programme revolves. If it weren’t for the the Daily Mail and its ilk and their constant banging on about how much better life would be if nurses hadn’t gone all hoity-toity higher-educated, it’s doubtful whether Who wants to be a nurse? would ever have got made in the first place. But it’s also the place where basing nursing wholly on subservience to public demands comes unstuck. Because what the public wants (or so we are reminded ad nauseum) is the abandonment of degree nursing. Nursing should be fighting tooth and nail to preserve it.

It was disappointing then, the the programme did so little to challenge populist assumptions about nurse education. Of the four students featured, only Amy seemed to have much enthusiasm for academic work. Charlee, in particular, confessed to having little passion for essay-writing, preferring to concentrate instead on being ‘the best practical nurse that I can be’.

But we need degree nursing precisely because of the conundrums identified elsewhere in the programme. Not just because research suggests better outcomes for patients where nurses have higher educational attainments (and what patient wouldn’t want that?) but also because it is only through academic enquiry and debate that we can attempt to answer Peter’s question about what a nurse really is, make a case for what works for us and for our patients, and reach the light at the end of the funnel.

Oh, and just before you turn off in disgust, Jeremy, and despite this week’s semi-climbdown on unsocial hours payments, you should have known that no one ever goes into nursing to be a millionaire.

It concerns all of us

By Basket Press

Trigger warning: Contains material that some readers may find distressing

Sexual abuse of children has been prominent in the news lately (for example here and here) and rightly so.

Why look at this in a nursing blog?

Well, it concerns all of us: many nurses will find themselves in a position where someone might disclose and must act on that information; the aftermath of abuse leads to mental and physical health problems so we will meet survivors; we often work in settings in which abuse could take place or has taken place; we will meet abusers; we must be able to recognise the signs and know what to do next. We cannot escape it. We cannot ignore it. My sister worked at Leeds General Infirmary; I have friends who worked at Broadmoor…

At least as far back as my nursing finals in the 1980s the potential importance of sexual and physical abuse in mental health problems was already pretty well established. One of the essay questions in my finals, set by the then English National Board, was about why a middle aged woman admitted to an acute psychiatric ward would have waited so long before disclosing childhood sexual abuse. This tied in with things I heard during my training from patients on acute wards and in community placements.

Now, note that I took my finals in the 1980s and that clearly, the UK nursing establishment, embodied by the ENB, was well aware of these issues. Scroll forward a couple of years and we have the 1989 Children Act, which generated much discussion about child protection matters and further demonstrates that the political establishment was aware of these issues.

I bring this up because it gives the lie to the claims made repeatedly by senior clerics of various flavours and other institutions that they weren’t so aware of child protection issues in the 1980s and ’90s. To be that unaware must have taken some great effort…

Then there remains the thorny question, which I have yet to hear answered by any of these senior clerics nor any apologists for abusers: at what point did you think sex with children was actually legal? Nor the related question: why do you think you are exempt from the laws which apply to every other person in the country?

Back to nursing…During my Child and Adolescent Mental Health Service in-patient days in the ’90s a certain young lady, who I will call A, was admitted with a mix of bulimic-type eating disorder and self harming, a constellation of behaviours we now know to be associated with abuse. I was her key-worker, and we developed a good working relationship, which allowed A to address many things while acknowledging that there was still something very important she was not able to talk about.

A went on home leave one weekend, as was standard for most of our young people, and took a massive overdose with clear suicidal intent. Fortunately she was found by someone coming home unexpectedly. When A returned to us from the medical ward I spoke to her about the overdose: she disclosed long-standing sexual abuse. The subsequent investigation led to prosecution of the perpetrator, whom I shall call Perp. To spell that out, the local police felt there was convincing evidence and the Crown Prosecution Service thought that it met their criteria for prosecuting.

Why mention A in this context? Well, Perp was a senior lay figure in a local church. A’s family were members of said church, which is how they knew Perp; not only that, but Perp was on the Diocesan Committee looking at vetting volunteers for working with children and was well known for being especially solicitous of young single mothers in the congregation.

It gets worse…During the trial of Perp (I was a prosecution witness because A disclosed to me) the vicar from the church came every day, sat at the front of the public gallery, glaring at every prosecution witness, tutting and harrumphing to the point that, as I was informed by colleagues, during A’s time in the witness box the judge actually warned him about his behaviour and threatened to have him removed.

Now, I will let you draw your own conclusions from the above two paragraphs…I drew mine, as did my colleagues and the local social services department…Subsequently at least two vicars in that diocese have been convicted of sexual offences against children.

On a brighter note, A worked through what she needed to and last I heard of her was heading off to a Russell Group university with a clear professional pathway in mind.

There’s a group of blokes I knew (I say blokes as they are very bloke-y), who grew up together, have been friends since school, went to the same church, where they were altar boys…And all bar one were sexually abused by the priest (they do discuss this publicly)…The one who wasn’t feels left out, that he wasn’t “special” like the others…The priest did, apparently, talk of his “special boys” who got “special treats”…

Amongst this group, two display what appear to be Obsessive Compulsive Disorder behaviours, two are heavy drinkers (and I mean HEAVY), one has regular, but not clearly explained, sickness absence from work. None have ever, as far as I know, sought mental health support…

I make no apology for using religious organisations as examples, as most of the stories I know involve such and I hold those who espouse an ideology of apparent caring and compassion to a higher standard than the man and woman in the street. There are, however, many more stories out there and many different institutions implicated in causing serious, life-limiting and life-threatening damage to young people, especially involving people in a position of power and authority (odd how that can aid grooming) who owe a clear legal and moral duty of care to those young people and yet choose to ignore that or to actively use it for other ends.

This is why I find the attempts by various official and semi-official bodies to squirm out of their clear responsibilities even more reprehensible.

Do you really want to hurt me?

The Chancellor’s announcement in this week’s budget that ‘pay rises for NHS nurses will be capped at 1% for the next four year’s should not really have come as a surprise. The Tories spent the whole of the last Parliament trying to starve nurses into submission over pay; a U-turn now was never going to be an option.

It’s no secret that the real goal in this protracted war of attrition is total re-negotiation of pay and conditions. Automatic pay progression and unsocial hours premia are the two objectives most directly in the firing line. The battle plan is simple: turn the thumbscrews of pay restraint so tight, that nurses will be forced to capitulate and accept the government’s alternative vision.

The government’s confidence that it will have achieved its aims by 2020 (and the next general election) were betrayed by another of the Chancellor’s budget-day pledges, the compulsory National Living Wage (NLW). Under the terms of this initiative, from next April all British workers over the age of twenty five will by law have to be paid at a minimum hourly rate of £7.20.

It’s not exactly a new idea: the National Minimum Wage has been around since 1999. From October this year, it will rise to £6.70 an hour for people over twenty one. Critics of the new ‘Living Wage’ claim that even though it represents a ‘hefty increase‘ on the Minimum Wage, it still won’t be anywhere near enough for the average Londoner to live on. On this reading, calling it a Living Wage is mere sleight of hand, or ‘a misnomer for political purposes’.

But from the nursing point of view, what are really interesting are the planned rises in the NLW over the course of this Parliament. By 2020, government estimates suggest it will be worth around £9 an hour. The pay band most directly affected by this is likely to be Band 2 – the standard pay band for health care support workers (HCSWs).

Current rates on Band 2 in England are hardly princely. A starting salary of £15,100 works out at an hourly basic rate of £7.72. This is a shade below the £7.85 outside-London minimum living wage as calculated by the Living Wage Foundation pressure group. Plug away at it for six years, and you’ll arrive at the giddy heights of top increment, where you’ll be clearing about £9.10 an hour. If the government sticks to the plans it announced in the budget, by 2020 this basic rate will have risen to roughly £9.47 an hour. There goes the luxury break in the Caribbean then.

But the real point is that the compulsory National Living Wage will by then be £9 an hour. (Some estimates put it at a slightly higher £9.15). Either way, the top increment of Band 2 will only just comply with it. Lower increment bands will be way behind, putting the government in breach of its own rules.

The only possible inference to be drawn from all this is that change is coming. It would be untrue to say that the advent of the National Living Wage is all about forcing through changes to NHS pay; there are many other agendas in play here, not least of which is the Tory party pulling the rug out from under Labour in order to portray itself as the friend of ‘ordinary’ workers. But it does represent a further turn of the screw.

I know that as a group, we have been shafted again and again and again – over pay, over seven day services and over safe staffing. I also know it will be very hard to trust the very people who have done this to us not to do it again. But this change is going to come whether we like it or not; and rather than painting ourselves as the eternal victims, it would do us more credit to be proactive, to examine the alternatives – not all of which will be as bad as we think – and to come up with a negotiating position that is more nuanced than just a blanket ‘no’. With pay rises capped at 1% for the next four years, the longer we leave it, the more we will end up hurting in the end.