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Back to the Future, Part Whatever

March 5, 2015

By Basket Press


The general election looms and the politicos begin to tell us what they have in store. Now, as I suggested in a previous post, we need to pay attention to things political, whether we like it or not. As this is a nursing blog I shall look first at direct mention of nursing – broader policy issues may be for another time.

And here in UKIP’s health policy we have an excellent example why we must pay attention.

Allow me to quote: “UKIP will simplify procedures for clinicians and nurses returning to work in the NHS.

• Nurse training should take place on the ward, not in a university lecture theatre. There is a desperate need to bring care and compassion back to the heart of nursing, to end the ‘too posh to wash’ attitude of some graduates and make sure patients never again die on our wards because their basic needs to be fed, given something to drink, and to be kept warm and comfortable are not being met.

• UKIP will bring back the State Enrolled Nurse (SEN); training will take place on the wards, utilizing the current pool of auxiliary staff allowing them to work toward becoming a State Registered Nurse.

• Nurse Managers will be responsible for ward cleanliness, the efficient operation of their wards, and oversight of nurse training on their wards.”

Oh dear…


State Registered Nurse? How long ago did that disappear? You do know that Health Care Aasistants can actually take further qualifications? And that they do already fulfil many of the old SEN roles? History not our strong point? Did we forget to talk to, y’know, an actual real nurse? Or even the RCN…


“Too posh to wash” – is it only me who shouts, “Evidence or shut the – expletive deleted – up!” whenever they read or hear that one? If someone, anyone, can provide me with convincing evidence, rather than Mail-esque “anecdotes”, that this really happens, then I will accept there is a problem to be dealt with, otherwise I will assume that someone has another agenda.


And if we look I think we can see what that agenda is: training on ward not in lecture theatre; training on wards; training on wards again. Let me see, that looks awfully like an attack on the whole concept of graduate nursing and a complete misunderstanding and lack of knowledge of current nurse training.


(I should issue a disclaimer at this point: I was a graduate before I came into nursing; I started as a nursing assistant before I did my training under the old apprenticeship model; I worked in one of the pilot areas for the original P2000; I have supervised/mentored students under every variant of training since then, as well as post-registration students; and occasionally done lectures and the like in my local university.)


I was long an advocate of greater theoretical under-pinning for nursing and a deeper understanding of the evidence base. One of the first things I did at the start of my training was question some statistics quoted by our tutor, who got out a copy of the relevant paper.Turned out they had misunderstood the stat=s and it didn’t show what they claimed it did…I remain convinced of the need for even better training in critical thinking, understanding of statistics and how to read scientific papers, so we know, and can explain clearly, why we are doing what we do and how it could be improved in the light of new evidence. Which is where, in part, the move to degree nursing comes in. The job has, inevitably given the advances in medical technology and overall knowledge, become more technical and training must reflect this if we are to avoid descending into irrelevance.


The lack of knowledge of the reality and diversity of nursing reflected in the above quote is staggering: in all the years since I qualified I have only had to wash one, yes one, patient, which is not at all atypical for mental health outside of elderly care, so yes, we do much more than ‘just’ washing; nurses are increasingly taking on roles previously carried out by doctors and are autonomous practitioners in their own right; does the UKIP spokesbod know that 50% of current nurse training is placement based? The constant use of “ward” reflects an ignorance of where many of us do actually work, i.e. NOT in hospitals. This ignorance and lack of knowledge is inexcusable in someone purporting to represent a serious political party with aspirations to form part of a government.


There are just so many “dog whistle” phrases in there, and it looks to me that underlying all that is an unspoken, but heavily hinted at, desire to return to some spurious golden age of Matron running everything (what else is the bit about ward managers if not that?), a nostalgic, revisionist Call the Midwife view of how things once were, a desire to pretend that the world has not changed…


I suppose I should be pleased that nursing rates a mention, but, ingrate that I am, I resent the misrepresentation, the inaccuracies, the harping back to a past which I hope none of us want to see again (my mother, for one, was glad to see the back of the Age of Matron and its inherent authoritarianism). Serious debate about the future of the health service and nursing’s role in that is to be welcomed: this, however, is not it. I hope we see something better and more coherent from other parties, but I am not holding my breath and, our host willing, will comment on those in turn.

  1. Also interesting that (to quote the BBC) ‘Under UKIP, migrant workers would have to have a job paying more than £27,000 a year before being admitted – but there would be exceptions such as nurses’. So they’re not envisaging big pay rises either…

  2. RGN007 permalink

    I am one who feels we have not gained a great deal in bringing in an all graduate workforce. I don’t fall in Farage’s image but I still appreciate what he is trying to do.
    I too returned to nursing as a graduate (we have discussed this before but someone rapped my knuckles as an old subject) but began my training as a pupil nurse and became an SEN.

    Titles bear too much on the subject. One can call them what one likes…SEN…trained HCA…Level 4…it doesn’t really matter but what I am passionate about is wanting to change the experiences and blockages I have had in nurse training.

    The “honours” part of my degree are 60 points at what now is Level 6 in Research, and the other 60 points is a module “Professional Judgement and Decision Making” BUT what I find really frustrating is I didn’t wholly need those modules to know latest practice and question existing practice. The stumbling blocks I came up against, was being considering a “beside nurse” and emptying the bins and BP’s if I was lucky.

    Examples of this was getting in trouble for not “washing” the patients lower back with the “bath” trolley, when I understood it was keep moving the patients gently that prevented pressure sores. Senior nurses would tell me “not to disturb the patient”.

    I questioned the practice of bending the arm up after taking blood and this later came to show it was pressing the area where the needle came out that reduced the bruising.

    As an SEN I realised the whole IT system for hospital in which I worked was rubbish so I made an appt to see the divisional manager to explain why.

    There were lots of instances and it was because I was keen to learn, read all the time, and not because I did a degree.

    Conversely we have doctors who have had to have a high level medical degree for years, yet we have poor doctors who do not apply what they have learned because many have no compassion, motivation or empathy to help the patients.

    We seem to have a situation for example, in Primary Care Nursing, where there is something about the philosophy of nurses that is different to those who choose to study medicine. Not all, but many seem to have noticed a pattern of difference. Nurse have a reputation for attending things in there own time, unpaid, because they want to know, yet we seem to have many GPs who have medical degrees who only attend if the occasion is incentivised.

    I think it is wonderful and essential that nurses can become graduates, but I don’t think they have to be graduates to be intelligent, questioning and evidence based nurses.

    I am now 61 and still feel proactive and keen to move with constructive change and had I had to so a degree first at 18 I would have failed.I almost failed when I upgraded to RGN but the University was so incompetent they promoted a lecturer to a senior position who did not turn up half the time to the course she run. Not only that but arranged duplicated tutorials at level 2 and level 3. To be honest, I do not have must faith in them. Also, whenever I had shown an interest in developing my knowledge to help patients further, I find there are many hoops to jump through in having exact “outcomes” to fit a particular institution even to the point of being expected to repeat all I have done elsewhere.

    It is the philosophy we need to test (even B&Q do it on their application website!)and find those with the right mental attitude and these are not necessarily high achievers academically.

    Let me quote you a little from a book I have by Howard Gardner in “Intelligence Reframed”. In his introduction he states,

    “We are faced with a stark choice: either to continue with the traditional views of intelligence and how it should be measured, or come up with a different, and better, way of conceptualising the human intellect…We must figure out how intelligence and morality can work together to create a world in which a great variety of people will want to live. After all, a society led by “smart” people still might blow up itself and the rest of the world. Intelligence is valuable but as Ralph Waldo Emerson famously remarked, “Character is more important than intellect.”

    My HCA had more character and fight on behalf of patients with no degree than most of the GPs we worked with who did have medical degrees. She did not need to study research to know how to do what was morally right.

    Nursing needs a co-operative working environment, not a bullying and competitive one. Evidence is important, but also is feeling part of a team and not being bullied into keeping quiet.

  3. Marieke permalink

    When I graduate in September, I know I will feel incredibly inadequate and not even half a nurse. Because I will lack experience. However, learning by doing is a very quick process. After inserting a catheter a few times, I will know how to do it. I do not need university training for that. What I DO need university training for is the ability to understand the wider implications of catheter use, insertion and care. So that I can not just act if something goes wrong, but also know what I can do to prevent things from going wrong in the first place.

    Learning on the job is great but it only trains you for things that happen. Which means that if unexpected things happen and you have to improvise, you do not have a knowledge base to fall back on. What university training has given me is the skills to go through things and logically come to a solution, even if I have never actually done it before. Because I have been taught where to find policies and best practice. Because I have been taught extensively about A&P. Because I have been taught that ‘just doing something’ is NOT always better than doing nothing.

    I feel that on the job training probably does produce more ‘useful’ nurses at the point of qualifying. They have DONE more things. However, my university training has given me tools to learn, reflect and disseminate. That is something you do NOT learn by just dong. That is something you need to be taught. Sometimes from a book. Or from writing an essay.

    On the job training used to be enough, when nursing was purely a practical job and when the doctors were responsible for what they told nurses to do. If nurses are to be accountable for their decisions, they MUST be given the tools and knowledge to argue why they do what they do. On the job training simply is not enough for what nurses have to do in modern nursing. Nursing has changed. And so education has had to change. If people prefer on the job training, then change nursing back to just being a doctor’s helper with no accountability.

    I am guessing nobody wants that.

  4. Barbara Bradbury, Halland Solutions permalink

    Me-thinks thou doth protest a little too much. Whether we like it or not we characterise any professional by the tasks that members of their profession traditionally carry out. Indeed, having a role title is a shortcut for us to know, at least to some basic level, who to go to and for what. We know, for example, that we go to a solicitor for legal advice. Furthermore, we might seek out a specialist solicitor who deals with one small aspect of the law, if we want help with one thing only.

    We are happy to go to the GP as the first point of contact in the health care system, understanding that we can present in the surgery with flu-like symptoms, a pain in the shoulder, recurrent nose bleeds, because we feel depressed – indeed, anything goes it might seem. We also are pleased to be referred to a specialist for our painful shoulder, someone who understands shoulders much more than nose bleeds, when the GP has reached the extent of their knowledge and skill.

    So, what do people expect from a nurse? There is a perception amongst the public that nurses are the specific professionals who care for patients in a way that other health professionals don’t. It is from this profession that they expect, for examples, help with washing when they are stuck in a hospital bed; help with feeding when they struggle to feed themselves; protection from getting pressure sores when they are immobilised; a bit of time for compassionate hand-holding when they are needing time to talk; the professional who will change their bed clothes when they are soiled; the person who will be around to offer them help to get out of bed or stand up from a chair whilst in hospital and needing assistance to get moving. These, and other things, are what the public think nurses do. I, too, think these are the things that nurses do – and I am a registered nurse, once known as a State Registered Nurse.

    Once upon a time, in the land of the SRN, many years ago before the age of computers, we called these things Basic Nursing Care (BNC). We, the nurses in this dinosaur age, knew very clearly what was expected of us as nurses – to provide BNC as well as other things. We took pride in providing BNC to a high standard. I did not think it was demeaning, just because I had a certain level of education. I knew this was part and parcel of being a nurse. Indeed, I understood this to be the very foundation of nursing. When doctors asked me why I had not become a medical student having started my life as a physiology undergraduate, I explained that it was nothing to do with academic ability, but the role. I was clear that I wanted to be a nurse and not a doctor. I constantly challenged the perception that nurses would not have chosen their profession if they had “brains”. Mine was a very deliberate choice.

    I remember endless discussions as a nurse undergraduate, as we grappled with the question “What is the unique role of the nurse?” Being the one profession who had 24-hour contact with patients (whilst in hospital), and the co-ordinator of all other health professionals, was about as good as it got. Little wonder then that the profession is still struggling with its identity.

    As an SRN, I ‘extended my role’ by doing things such as IV administration. I didn’t see this as taking something away from the doctor, rather I was simply adding another skill to my set in order to give better care to patients – timely administration of drugs being part of my role as a nurse. I didn’t stop giving BNC just because I added another task to the day.

    From the day I qualified I had to learn how to manage the ward as a registered nurse, a role that I felt prepared for as I had been given much opportunity to take charge of wards whilst I was a student. Of course, it felt quite different being in charge as a qualified nurse to when I was a student. However, I was keen to ‘step up to the plate’ and show how my training and education HAD prepared me for the role. This is not how things are today.

    There is a big difference to how I was trained and educated in the 70s and 80s and the training and education that nurses receive today. I would say the biggest difference is that I was prepared for all aspects of my role and, significantly, to lead – to take charge of a ward, from the day I qualified. Nurses today are not prepared for this role or, indeed, for the responsibilities that come immediately when employed as a registered nurse. I am baffled by this. How can we be providing a training and education that does not result in nurses who are prepared and fit for purpose? They need copious support and mentoring during their first year post-qualification, in amounts that do not stack up. I can only conclude that their training and education leaves them far short of the skills, knowledge and confidence that they need in order to ‘hit the ground running’ – in forward motion, not away from the action!

    An example that illustrates this – and this is by no means an unusual situation in my experience: I was told by a Band 6 ward manager earlier this week that, when there is no Band 6 or 7 Manager on duty on her ward, none of the Band 5s want to be in charge of the ward – and each has been qualified for more than 2 years. To me, this is beyond comprehension. Of course, it says something about the Band 7 leadership and management but, putting that aside, why is it that Band 5 nurses shy away from responsibility? (And, this is not confined to hospital-based nurses.)

    A different Band 6 nurse told me the previous week that the first thing she tells all students and newly-qualified nurses on her ward is: “I never want to hear you say, ‘I don’t know – she/he is not my patient’. I also don’t want to ever hear you say ‘that is not my job’.” This nurse, who is not of dinosaur age, was very clear that students emerge from college with unrealistic expectations of what is and isn’t nursing. Again, this is not an isolated example – sadly.

    Back to the perceptions of UKIP and the rest of the public: strange as it may seem, it is these things that I have called BNC that are the things that characterise nurses from the general public’s perspective. Furthermore, I and many, many nurses that I work with today agree that these are still tasks that are within the remit of nurses. After all, if “Basic Nursing Care” isn’t the responsibility of nurses any more, whose responsibility is it?

    This is not to detract from the rest of the things that we do as nurse professionals – administer medicines, provide specialist care to patients returning from major and complex surgery, take responsibility for administration of chemotherapeutic drugs, and whatever else is required as nurses in our clinical environments – using our knowledge and skills to underpin the activities that are required of us on a daily basis.

    And then, there are the administrative and management tasks – sorting out the ordering; off-duty; annual leave; liaising with various other professionals; monitoring budget spend; staff appraisals; and so on and so forth.

    It seems to me that the role has grown and, as we have taken on ever more tasks that were once the province of other professionals (including managers), we have forgotten the roots of nursing, that is the Basic Nursing Care. Instead, we have passed this over to Health Care Assistants, who then become nurses by task but not by name.

    Back in the dim and distant past, pre-historic to me, nurses fought to be seen as professionals. They argued that providing BNC required specific knowledge and skills. A whole ‘body of knowledge’ grew up with BNC – books were written on the subject. Ensuring that we knew what it meant to provide BNC was part of the examination process (in the dinosaur era) – heaven help those who forgot to include in their essay that they would ensure that a sputum pot and tissues were placed within reach of the patient who had a productive cough.

    Yes, we have advanced from the sputum pot and tissues – is this because of money or because we have forgotten good BNC? Do we, the registered nurse, have more important things on our plate these days? Possibly. But, who is going to provide the BNC – because it still needs to be done. And, the public thinks that is what nurses do.

    I think it is about time to start thinking again about that old chestnut “What is the unique role of the nurse?” Because I don’t think we have ever answered it adequately. If nurses can’t agree what is nursing, how can we expect the public to? If nurses don’t want to give basic nursing care anymore, do we formally give the title ‘Nurse’ to those that do – the HCAs in many instances.

    Nurses have always been in danger of becoming “Sweeper Uppers”, sweeping up the tasks that other professionals once did and are either too stretched to now carry out those tasks, or developing the skills and acquiring the knowledge to take on new tasks as they wish to stretch themselves – prescribing, advanced clinical assessment, etc. All of which is understandable. However, if we take away BNC from the responsibility of a “Registered Nurse”, are we really creating a new health care professional?

    There are a number of questions, for the nursing fraternity, as I see it:

    Why are nurses not proud to be the provider of BASIC NURSING CARE? Why do these discussions always come back to whether or not nursing should be a graduate profession? If nurses think that basic nursing care is not the remit of nurses, what do they think is the role of the nurse? If basic nursing care is no longer to be central to what nurses do, should we be redefining nursing, or finding a name for the professional undertaking the tasks that this ‘new’ role requires? (Sweeper Upper?) If nurses want to pass basic nursing care on to someone else (e.g. Health Care Assistants), do not the HCAs become d*e facto *nurses? Should nursing go back to its roots? If not, why not?

  5. RGN007 permalink

    The following is from the Maria Montessori Facebook site, a woman who specialises in the education of children.

    I think choosing nurses from these qualities would benefit patients and the profession more than looking at just academic achievement alone.


    critical thinking
    question asking
    sense of beauty
    sense of wonder

  6. CALDWELL, Chris permalink

    Ok ta

    Chris Caldwell Dean of Healthcare Professions Health Education North Central and East London

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