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Glad Tidings of Great Joy

December 9, 2014

I had a D’oh! moment the other day. It happened as I read the Nursing Timesreport on the progress of Lord Willis’ Shape of Caring review – a tantalising sneak preview of which was revealed at the CNO summit last month. A few weeks earlier, I’d taken part in a Twitter conversation about nursing careers. At one point the esteemed @Joanne_Hodge, who takes an interest in these things, tweeted that community nursing should be a separate degree. ‘Note to self’ I thought. ‘Intriguing suggestion…future blog?’

Well – you know how it is: other stuff came up, and the idea got shelved. I lived to regret it though, as I read Lord Willis’ hint that in a re-structured nurse education programme, community nursing could become a strand in its own right, much as mental health and learning disability are today. “We are going to see a significant shift into more community and domiciliary care” said the noble lord “that’s a fact”. Hindsight’s a wonderful thing of course; I wish I’d gone with the ‘community nursing degree?’ thing now. Had I done so, I’d be basking the warm glow of readers’ admiration of my journalistic acumen and instinct for scenting out a story. Oh well…

Notwithstanding any of that, however, in the run-up to Christmas I can’t tell you what a joy it is to report on a story that I feel entirely positive about. The news that Lord Willis’ proposals ‘could see student nurses undertake two years of general training before moving on to their preferred area of specialism in the third year’ is something we should endorse wholeheartedly. (I’m assuming that what is meant by ‘general’ is not ‘obligatory adult general nursing for everybody whether they like it or not’ but a ‘common’ or ‘combined’ study of all aspects of human health.)

Honestly – this is the most sensible idea I’ve heard of in ages! Why? Well for one thing because, at least as far as the mental/physical health interface is concerned, we have some very urgent problems. Earlier this year, research conducted by Oxford University and reported by the Mind mental health charity concluded that ‘serious mental illnesses reduce life expectancy by 10–20 years’ – a terrible toll that all health care professionals should want to address. Of course, this statistic is underpinned by a shameful litany of other contributory factors – poverty and unemployment to name but two – and no one’s suggesting that a change to nurse education is the thing that’s going to solve them at a stroke. But it’s got to be a start.

The Guardian Professionals Network recently published a very brave and honest account of the panic and helplessness one general nurse confessed to feeling around unstable mental health patients. And I would guess that a companion piece could easily be written by a mental health nurse about the doubt and uncertainty they sometimes feel around the management of physical conditions.

The reality is that mental and physical ill-health too often feed off each other in a tragic cycle that goes on for years. And however good our intentions – if our training encompasses only half that cycle, we can only really treat half the patient. To put it in terms of the 6Cs (I don’t do this very often, but hey! it’s Christmas): Care? Certainly. Communication? Difficult, if you’re ‘shit scared of saying the wrong thing to someone who is vulnerable’ (as someone who commented on the Guardian piece put it). Competence? See ‘communication’…

At the same time as Lord Willis is hinting at greater convergence, he is also, paradoxically, hinting at more opportunities to specialise. But the possibility of a degree in community nursing is firmly rooted in health care reality. In future – well, actually, in the present, but that’s another story – we are going to need nurses with the skills to keep patients in their own homes and out of hospital. Specifically, they’ll be people whose expertise is in the management of complex needs and long-term conditions. Recognition that this is an area that merits a new cadre of professionals with their own specialist knowledge base would be a huge step forward.

But amidst all the rejoicing, we still have to be on our guard. Firstly, the Shape of Caring review panel is due to produce its final report in late January. That’s a mere three-and-a-half months before the general election. We know Lord Willis is going to make good and sensible recommendations; vigilance will be required to ensure that in the hurly-burly of an election campaign, they don’t simply get kicked into the long grass – especially if there’s a change of government in May.

Secondly, if educational preparation is going to incorporate a suitably rigorous academic element, but also a placement component that is ‘much more “intense” and “practical” than the current provision’ (as Lord Willis also told the CNO Summit), we may find ourselves looking at a four-year degree (suck it up, Daily Mail). Personally, I don’t think this is a bad thing – but to make it work, we have to do something about bursaries: most courses at present last three years, but even so, there are far too many stories of frightening financial hardship endured by students. Now of all times, the last thing we need is to see good people deterred by the prospect of four years on a below-poverty-line income.

A solution however, may be within our grasp. Another of Lord Willis’ hints was that he’s considering a model that ‘also include[s] a further year, post-qualification, of preceptorship’ – and this, I think, is a potential game-changer. I see it as a mixture of study and supervised paid practice, where participation in research, or the incorporation of research into practice is an expected outcome. I see it as chance, in short, to bridge the theory-practice gap and transform culture. Idealistic? Of course – but hey! it’s Christmas.

 

 

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18 Comments
  1. Basket Press permalink

    It certainly depends on what “general” means…

    My experience, having done the old style apprenticeship training in the ’80s and then supervised/mentored students for 20-odd years, is that the 3 years of MH training is barely enough to produce people who are safe practitioners in MH. If this is further diluted that will be dangerous. Preceptorship only goes a small way to fixing this.

    However, it is fairly unarguable that MH nurses do need a grounding in physical health and also that “general” nurses need to know more about MH. Is this achievable within 3 years though?

    I would also like to see more attention given to assessment of evidence, how to read papers, critical thinking and the like: it was a huge annoyance to me when a student would tell me “research shows”, only to find that the “research” wasn’t actually research as I understand it (disclaimer – I have a science degree) and didn’t really show what they thought it did or contained huge statistical and methodological flaws. Some of the things I heard were not what I would expect of an undergraduate.

    It will be interesting to see what Willis finally proposes, but I fear that politics as usual, the current austerity narrative and the increasing fragmentation of healthcare will send it the way of many other reports…

  2. Hi Basket Press. Thanks for commenting. I think you put your finger on it when you ask whether three years is enough time to assimilate a working knowledge of multiple aspects of nursing plus placement experience plus the development of a rigorous critical approach. Interesting that the Nursing Times website was today reporting that Professor Jennifer Corner, Chair of the Council of Deans, has voiced similar concerns.
    Are we then heading for the four-year degree? At least one student who responded to this post over on Twitter seemed fairly relaxed about the prospect, tweeting that ‘a 2+2 generalist/specialist degree is the way forward’.
    The real answer, I think, hinges on getting the balance right between pre- and post-reg education, and I do wonder what the training institutions’ view on that is. We’ve only just bedded-in all degree nursing. Is there appetite for yet more change in the Groves of Academe?

  3. junegirvin permalink

    There’s always appetite for changes that improve things! I am cautious, because however good Lord Willis’ intentions, as always, I suspect that speed and cost will result in some pale imitation of the original ideas. 2+2? Maybe. 3+1? Maybe. 2+1? It’s not going to do it. It will be the cheap option and it won’t help anyone.
    I’m also not sure what more ‘intense’ and ‘practical’ means in terms of placement. Longer placements? Maybe. Longer time in a poor placement? Please god, no.
    I’d like to see formal recognition of the importance of practice education in service areas with the development of very senior posts with a responsibility for practice education in Trusts. People who have studied work-based education and continue to study practice pedagogy. Supervision of practice education? A basic level of supervision skill for every nurse, and Mentorship formalised as a career option and NOT for everybody.

    Basket Press makes an excellent point about the understanding and utilisation of evidence. This should be another career option, or ‘speciality’ that could be the +1. Three years to registration and then straight into an MRes anyone? Yes please.
    Let’s think beyond the clinical specialty here, lets think about that ‘specialty’ option as going well beyond child, adult, mental health, learning disability or community. Let’s think about public health, practice mentor, researcher, teacher…

    if we are going to fundamentally change nurse education, let’s be ambitious about it, and willing to make the investment it will need.

    • Hi June – I was hoping you might comment. I think the quality of placement environment is the elephant in the room here. Lord Willis’ earlier report for the RCN and the seminar discussions that formed part of Robert Francis’ investigations both spoke of placement quality as crucial to improving standards. Re-structuring nurse education will achieve nothing if we don’t take action to ensure a uniformly high quality of placement.
      It would be great to see Trusts and other service areas being proactive in this area. I’d love to see more attention paid to the continuing development of mentors, and a career pathway for nurses who want to specialise in practice/research education. The issue really is variability: there are some excellent placements and mentors out there, but few mechanisms for energising the less-good and bringing them up to standard. An awful lot to think about…

  4. RGN007 permalink

    I am one against compartmentalised degrees. I think they potentially exclude a range of potential carers that may lack some of the criteria to get through the hoops of many institutions, but may have a higher level of compassion and insight through emotional intelligence.

    I favour starting out as a health care assistant before choosing direction, then choosing modules and develop and grow as we discover areas of care we feel drawn to.

    Had academia been present at the beginning of my career I would never have returned to nursing. Even though I felt able at school, I failed all GCE’s and never got to A levels. I passed the old General Nursing Council test three times, the last time apparently getting the highest mark the nursing school had ever had but circumstances meant I only had time to complete a 2 year bedside nurse SEN training. I then ran a business with my husband and had three children…and developed my interest in learning again as well as a little more confidence.

    The Open University provided a wonderful eclectic environment to study a blend of what I wanted to learn and, as their old “open” degrees allowed, I could begin with science and information technology, then attached these to various forms of health modules. When I graduated I thought what could I do with such a concoction. I later found not only did these transfer well in upgrading my SEN to a Level 1 RGN nurse, but it gave me an excellent grounding in becoming a practice nurse.

    The next progression was wanting to study more to help patients so the next level were a succession of specialised modules at honours level (old level 3), then a couple at Master’s level.

    What has been really frustrating along my flexible and self-motivating pathway has been the rigidity and expectations of individual academic institutions such as one who suggested I should complete a BSc Hons in Specialist Practitioner in Practice Nursing.
    “Ok” I said. “I have 680 CATS points of which 60 are Hons level in Research. Will this count towards this specialised degree?”.
    “No, you’ll have to repeat them at our university.”
    “No thank-you. Are you serious?”

    I continued asking the question of what really benefited patients (and my motivation) the most. Wasting time repeating core modules that may have some slight deviation of those I had already covered, or continuing with modules directly useful in disease management.

    I am aware it is contradictory to the current trend in an all degree workforce but it is not the ultimate degree I object to but the process of rigid hoops these institutions make us jump through in the name of a generic style qualification.

    Look at many of those who get through a medical degree, yet have little ability to apply their knowledge even though they pass with high marks in the examination room.
    Look at how many wonderful health care assistants we have who have no degree yet we may trust them more than many of our “trained” colleagues, especially with their interpersonal skills.

    I think nursing could be the leaders in a more innovative method of training and be more accepting of diversity. I liked the idea of a trial, I think it was in Liverpool, where the first 18 months training was shared by both medical and nursing students then aptitude, ability and choice allowed those to go on to their direction.

    I liked the trial at St Georges in London, some years ago the subject of a TV documentary where an intake of medical students could be anyone with any mediocre degree and who came top? An ex nurse with a class 3 geography degree!
    I think she shone in the communication element.

    • junegirvin permalink

      Hi RGN007 and Grumbling Appendix,

      RGN007’s comment really resonated with me. I did my nurse training in the nineteen seventies when degrees were years away (I am even older than Grumbling Appendix!). I don’t have a first degree and did a Masters in my mid forties, part time – for my own interest and my own benefit. My lack of a degree qualification in nursing never stood in my way in practice and my (mid-life, part time) Masters has never stood in my way in academia (where Masters is a pretty lowly qualification). But the desire to learn and understand, the thinking skills, the stimulation of studying has really helped me and kept me moving forward. My Masters dissertation focussed on leadership and nursing and has been underpinning my working life ever since. I wish I had understood at the beginning of my career the benefit of the structured and rigorous ‘training’ for my brain that degree gave me. I would have been a better nurse for it. Sadly, in the seventies, girls of my background had no encouragement to go to university, I failed my A levels too, but university had never been on my horizon. I was always bright, but it took until I was in mid-life for me to decide that higher education would fill a huge gap for me and contribute to my capacity to do a good job.

      There are many routes into a nursing degree – A levels aren’t essential – there are a wide range of access routes and equivalencies taken into consideration, and I believe (because I see it in our own students in the university I work in) that the students we recruit are no more or less compassionate or caring than any in the past – and I can look back on a good forty years of unbroken experience in the NHS and in higher education.

      Having a degree qualification is a proxy for intellectual capacity, the ability to learn and change as a result of that learning, the ability to analyse, synthesise and make decisions based on evidence and best practice. Nurses need that.

      Some nurses may demonstrate those abilities without a degree, but for employers having to recruit people they do not know, having a degree is shorthand that says ‘I have these skills’ as well as the specialist subject knowledge. It is those ‘graduate skills’ that can enhance the future capability and contribution of the qualified nurse. For patients, knowing that their nurses have a degree in nursing should be a reassurance and a comfort that they are in capable, knowledgeable hands – instead there is a dangerous media message that knowledge and compassion are somehow incompatible.

      It is a major step forward for nursing to be a graduate entry profession. It is a major benefit to patients for nurses to be intellectually competent as well as practically competent. I look forward to the time when a Masters degree is the norm, and senior clinical nurses carry the title ‘Dr’ through rigorous research activity in their chosen specialty which they translate into better care and better outcomes.

      I hope when I need to be nursed that my nurse’s name badge says “Hello, my name is xyz and I’m RN, BSc, MSc(Elderly Care)” – as a minimum. In fact I wish name badges carried qualifications now – for the purposes of transparency to patients. But that’s a whole different blog comment!

  5. Hi RGN007 – thanks for commenting. You raise the interesting subject of what happens to nurses whose qualifications get ‘overtaken’ by new initiatives in nurse education, and how to ensure that one, we don’t find that good nurses get left behind and two, nurses trained under different dispensations are given the opportunity to update or ‘convert’ their qualifications if they want to.
    To some extent, I’m a victim of this myself: I entered nursing in the mid-nineteen eighties with a good degree in modern languages. I and my fellow graduate-entrants were told that, with a nursing qualification added to a degree, the world (to quote someone who has commented on a similar theme on another post) would be our oyster. A few years later, however, it had became obvious that the profession now viewed my non-nursing degree as irrelevant. Your degree had to be in nursing, or you might as well not have one. At that point, I realised I had to start work on a Master’s, in my own time and at my own expense, of course.
    I think maybe June’s idea of a senior posts with a responsibility for practice education in Trusts has something to offer here. I don’t imagine help with expenses would be on offer, but it would be helpful to have a designated person available to help staff navigate their way through the plethora of courses and pathways on offer and, if need be, maybe negotiate on with educational establishments of behalf of individuals with previous qualifications. We definitely need a stronger bridge between the service and education sectors.
    I remember that programme about the medical school that offered accelerated medical training to students with degrees in other disciplines, and the nurse who came out on top. Wonder what she’s doing now?

  6. June, that’s one of the most eloquent expositions of why nurses need degrees I’ve ever read. Thank you for posting it on my blog.

  7. junegirvin permalink

    You’re welcome. But if you don’t mind – I’ll post it on my own as well tomorrow!

  8. Bunzbird permalink

    Going right back to GrumblingAppendix’s original post, which mentions the nurse who felt completely overwhelmed by unstable mental health patients, took me back to my first post as a community nurse, fresh from the factory.

    Colleague: ‘He needs steroid eye drops every day, AND he’s schizophrenic! We’ll need to go in pairs.’
    Me: ‘Why do we need to go in pairs?’
    Colleague: ‘Who knows what could happen, could be dangerous.’
    Me: ‘I don’t see why having schizophrenia makes him dangerous?’
    Colleagues *bit of eye rolling* because I clearly didn’t see the ‘risk’

    And so we visited in pairs. And no we were never in any danger. But we continued to visit in pairs, because, errrm. Simply out of ignorance I suppose. I wanted to feel cross at them, but they meant well, and I suppose I was more annoyed that nobody seemed to have any understanding of mental health issues, which genuinely surprised me.

    I guess I’m the new kid in town, having only qualified 4 years ago, I’m one of them new fangled lot that apparently doesn’t like wiping bottoms, or talking to patients in general. I started out as a student mental health nurse, but my frustration at being unable to assist people with their physical problems was one of the reasons I left (the others reasons would make for a lengthy off-topic post). I wanted to know how to apply a basic dressing to someone who had self-harmed, but nobody really knew what to do, so off we’d trot to the ED. I felt a bit embarrassed to be honest. And the patients with diabetes, brought about by the weight gain exacerbated by their psychiatric medications, what did we do to help them?

    I managed to swing a transfer to adult nursing where I completed my course, but looking back my year in mental health proved invaluable. My fellow adult branch students did a couple of online modules in mental health, and that was it, and I fear they may have graduated with the same ignorances as my lovely but ill-informed colleagues from the community team.

    I’m not one to hark on about the good old days because for me there are no good old days. But I do hear that student nurses of old would get experience in a practice area outside of their chosen field, and that doesn’t seem to happen these days. I know our university had problems finding enough placements to accommodate all students, so to insist on specific practice areas would probably have broken them.

    I absolutely concur with JuneHE’s comments on graduate education. However I have a theory around why we seem to keep having this merry-go-round debate. Who are nurses? What do they do? What is their role? I think it really depends on the person’s perception of nursing (and that includes fellow nurses) as to what sort of education you think they should have. To some, everyone in a tunic is a nurse (even if paired with leggings), so why bother slogging it out writing ‘pointless’ essays. And at the other end of the spectrum we have confident, knowledgeable practitioners, armed with the tools to shape, develop, challenge, and deliver high quality care, based on a graduate education. I know it’s going to be an uphill struggle to convince everyone that all graduate entry is a positive move for patients, but it’s clearly not putting off thousands of potential student nurses who seem keen as ever to begin their journey. Now how can I get on my MRes…?

  9. Basket Press permalink

    Interesting point about “Who are nurses?”

    In my last job a couple of my more senior and long-standing colleagues and I (we’d been staff nurses together in an earlier life) discussed this regularly and came to the conclusion that of all the clinical disciplines in our service (art therapy, psychiatry, psychology and occupational therapy were the others) nursing had the least well defined professional identity and role and as a result of this we did all the things everyone else said they couldn’t or shouldn’t and ended up being the glue that held the service together. Which made us more valuable in many respects…We thought.

    OK, that was a community setting, but we thought back to our time together as staff nurses on an in-patient unit and reckoned the same was true – we’d been the glue that kept the place together, doing all the unglamourous day-to-day necessary things.

    As an aside, but kinda related, my experience was that good old-fashioned gender stereotyping is still alive and kicking: I am of the male persuasion, always, but always, introduced myself as “Senior Nurse Basket Press, but call me My First Name”, had the staff ID badge with senior nurse on it but the number of people who were incapable of recognising my inherent nursey-ness and referred to me as doctor, psychologist, counsellor, whatever. This did not happen to my female colleagues…

  10. Hi BunzBird and Basket Press. Interesting. I often hear male nurses (particularly students, for whom it’s still a novelty worthy of comment) say that patients think they are doctors. Says a lot about the public’s ingrained ideas about what a nurse ‘is’.
    On the subject of nurses being the ‘glue’ that holds everything else together, this reminded me of Celia Davies’ argument that nursing is not a ‘profession’ in the accepted sense of the word, but rather what is left over after a profession has defined itself. Discuss.

  11. junegirvin permalink

    Good old Celia Davies, eh? Still on the button after all this time. I’ve really enjoyed this exchange of views and Basket Press and Bunzbird swinging by with great comments that keep us thinking. It does sometimes feel like a pointless argument and I’m one of those people that usually says ‘don’t engage with discussions about nursing not needing to be a graduate profession because it is now, so get over it’, but I just can’t help myself!

  12. RGN007 permalink

    Thank-you June. If ever someone would persuade me to an all graduate entry into nursing profession, yours would. I take your points and can see the benefits of the structured and deeper thinking. But as a newcomer to Grumbling Appendix I hope all will forgive me not being party to the debate on nursing being an all degree profession being on an earlier roundabout, though I am sure there are various perspectives to consider and always will be.

    I am passionate about the structure of education generally (even if we leave the degree ad nursing bit alone), because I have had a series of bad experiences, not only myself, but students alongside me felt the same. One example was a surgical module at Manchester, where the lead tutor did not know dates and lectures and 30% were duplicated on the second module and another 30% did not turn up. This person was later promoted. I failed that exam twice, but the aggregated marks gave me a single mark that allowed me to count it to passing from SEN to RGN Level 1. Ironic, because I struggled less with the less structured higher modules. I didn’t feel stupid ut was made to feel stupid. My application to caring for patients appeared to be often be reported by the patients themselves as “Why has no one else thought to explain to me like you”. I often used alternative thinking not running with the herd, like the time a patient disappeared and I went a different way instead of milling around in wonder with everyone else, and I found the patient. I could name various instances. I did feel the consultant was impressed and saw me in a new light (smiling). I was always happier doing the beds or emptying the bins, but could click into a new gear when senior staff did not turn up. My dissertation on a critical event being the lack of insight into use of effective information technology was seen as applicable to patient care in 1997 but I was a bit phased when my name came up in a list of contributors on The Royal Society website about the impact of digital healthcare around 2007.

    I am now 60, but not ready to retire yet, but I suppose I am at a point where education from scratch is not so relevant to me. I doubt I am unique, but I don’t feel I fit into the mould of the cohorts who would now gain access at all. Having a son I diagnosed with Asperger Syndrome, and 12 years later it being confirmed through a diagnosis process I fought for in my region through complaining via my MP, then meeting with the mental health officer etc etc. I am very frustrated about pigeon holing people because we/they do not fit into initial criteria and judgement of others and their tick boxes.

    It scares me to think my contribution to caring for patients could be judged by a few marks lacking and be excluded on the basis there has to be cut off point somewhere. I only passed English O level at the third attempt, but apart from that progressed on because I was keen to learn, and like June, paid for these myself and in my own time with the exception of two modules. My experience at university has not been a happy one, nor have I been impressed by the quality of the some of their structure.

    Take a surgical module, or lets say the two that were to form a certificate. The lead tutor was not respected by those on the module as she appeared to not know from week to week what we were doing. She seemed incompetent, and several of the lectures were repeated by the same person, if they bothered to turn up at all. One poor student was not told she had failed the first module before she had to enrol and pay for the second module. The lecturer was offered a more senior position and promoted!

    It do not wish to bore all with individual experiences, but there were many. I used to wonder who should be marking who.

    I also work in an area where I am employed by GPs and I am constantly baffled at how those with all graduate profession can such little insight into many aspects they have responsibility for. I know not all are the same and there are also very good GPs. However, I have also had the misfortune to work for 8 x GP practices since 1999 whose all graduate employers were lacking in one direction or another that did not demonstrate all the qualities one would expect from that deeper level of thinking.

    I dread nursing falling into the same hole where nursing has the potential to use all areas of intelligence, not just academic. Not sure if I mentioned John Gardner’s “Multiple Intelligence” earlier, but if nursing embraces diversity, then although a degree or two is useful, it is not in my experience the gold standard of judging ability.

  13. Basket Press permalink

    Bit more on what Willis is likely to say:

    http://www.nursingtimes.net/nursing-practice/specialisms/educators/exclusive-lord-willis-reveals-thoughts-on-nurse-education-reform/5077641.article?blocktitle=News&contentID=4385

    This comment – “They [students] might do two years of really detailed rigorous general nursing and then begin their specialism in the final year and run that on into preceptorship,” he said. – doesn’t fill me with joy…

    That would have been enough to put me off, and quite a few other MH nurses I know. I not only knew I wanted to do MH rather than general, but which bit of MH.

    As I said above, that will NOT produce safe MH nurses: a year is completely inadequate, even with the cop out of “run that on into preceptorship”, which is essentially acknowledging that a nursing degree is not going to produce people who can actually do the job. And does not address the points made above about general nurses needing more education in MH…

    Who has he been talking to?

  14. Hi Basket Press – thanks for the heads-up. I think there is some potentially good stuff in there like recognition that a clearer career pathway is urgently needed and that mentoring is a specialist skill for which not everyone has an aptitude.
    On the other hand, you are right of course, that an awful lot is hanging on the interpretation of that world ‘generalist’. Does it mean ‘general nursing’ or does it mean a ‘common’ education that embraces all aspects of nursing and health? In the original article, I (perhaps rather generously) took Lord Willis’ meaning to be the latter of these two. However, this new article from the Nursing Times seems to bring it closer to the former, which is very concerning. I completely agree that two years of ‘detailed and rigorous’ general nursing would simply serve to put off those who wanted to specialise elsewhere. Even worse, it almost smacks of a way of sourcing cheap labour for over-stretched general wards.

  15. Basket Press permalink

    Mentoring is a whole other set of annoyances: my old trust and the associated university were somewhat slapdash in their approach to and support for mentors, especially following the move to “sign off” mentors.

    Personally I was always happy to be a mentor/supervisor, but felt that my management did not recognise this in terms of allowing any variance in caseload when having a student, and the annual “mentor updates” were laughable, let alone the invisibility of tutors even when a student was on their final “signing off” placement.

    I’ll stop there before this becomes a major rant.

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