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Shock as Grumbling Appendix ‘agrees’ with CNOE

June 16, 2015

D’you know what really annoys me? What really annoys me is when I ask if a patient is getting out of bed, and some world-weary staff nurse shrugs and gives me a dismissive “Oh, just leave him for physio”. For some reason, it’s a response that seems more common when the patient in question is large, immobile and hoist-dependent. A lot of work, in other words.

It annoys me even more when it’s a Saturday and you know damn well there will be no routine physio until Monday morning, and the family, due any time, will be upset to find granddad slumped in bed instead of up in the wheelchair, waiting to be taken out for a change of scene. Did I miss the policy decree that mobilising patients was no longer a nursing duty?

It’s scenarios like this that incline me to agree with Jane Cummings when she said (in her 3rd June letter to Ian Cumming and Simon Stevens) that ‘when we consider overall staffing levels, it is crucial that we now look beyond traditional professional boundaries’. Unfashionable it may be to make this point in the current climate, but what’s the point of complying with Safe Staffing guidelines if nurses are still determined to hole themselves up in professional silos?

Although history will probably remember the Chief Nursing Officer’s June 3rd missive as the one that contained the now-notorious words ‘This means that the programme of work [on safe staffing] commissioned from NICE could be stopped’, its main subject-matter is actually workforce planning. Its ambitions on this front are at times opaque (can anyone tell me the meaning of ‘This will require the whole health and care system to…streamline international recruitment where necessary’?) and even sinister (does ‘we will need to target our workforce at the times of day and week when they are most needed’ herald the return of the split shift, for example?). On one area, however, it is clear: the need to develop the ‘critically important’ Health Care Assistant (HCA) workforce.

Because of their perceived potential to solve the staffing crisis in nursing, HCAs, for so many years the Cinderellas of the service, have recently become the focus of intense interest. But despite Jane Cummings’ insistence that ‘a clear competency based career ladder for care assistants is being developed by Health Education England’, what we appear to be presiding over in reality is a fragmentation of the role.

In a particular dither is the Royal College of Nursing (RCN). Its official line on HCAs is merely that it wants to see ‘improvements in career development’; its outgoing Chief Executive Peter Carter, on the other hand, reportedly told former Lib Dem Care Minister Norman Lamb that his private view was ‘that we should re-introduce something akin to the SEN, the State Enrolled Nurse’. Meanwhile, in his Shape of Caring report published earlier this year, Lord Willis called for a new Senior Health Care Assistant role ‘designed to bridge the gap between care assistants and registered nurses’. And this is on top of the already-existing Assistant Practitioner grade.

With the emergence of so many job titles and competency levels, the danger is that we end up with simply a proliferation of new silos – the complete reverse of the holistic, person-centred care we need. Additionally, there is a crying need for nursing to take the driving seat on initiating debate about what these new roles mean for its future.

A recent analysis of the nursing home workforce, reported in the Nursing Times, concluded that ‘the UK [could] go down a similar route to France and the US, where registered nurses take on a more specialist role that involves supervising the work of care staff’ and quoted the Chai Patel, Chief Executive of a nursing home company HC One as saying “We need to use nurses more judiciously and effectively rather than generically.”

It’s against this background of staff shortages and role re-appraisal that the safe staffing debate needs to be seen. In a second letter to all English Directors of Nursing, Jane Cummings said that ‘the ultimate outcome of good quality care is influenced by a far greater range of issues than how many nurses are on any particular shift, even though that is important’.

Regular readers will know that in the past I have been unafraid to criticise the Chief Nursing Officer – for some reason, the subject of the 6Cs springs to mind here – but on this occasion, I happen to think she’s right. If nurses want their profession to survive in its present form, and don’t want to find themselves increasingly pushed into some new kind of management silo, we’d better start telling the world exactly what that ‘greater range of issues’ is. And soon.

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4 Comments
  1. Basket Press permalink

    To define that “greater range of issues” throws up another problem, which we touched on in the comments below another recent piece of yours: research.

    I identified then the difficulties faced by many nurses in being “allowed” to conduct any research, however there is another difficulty which BTL comments on many NT pieces highlight: there was a news item yesterday about some research which tentatively suggested that longer “recovery periods” between shifts were beneficial in health terms; the first BTL comment was dismissive of the research and the researchers, while claiming that we all know that anyway so why bother doing research to show what we all know anyway; this sort of comment is pretty normal under any piece reporting research – “just ask ward nurses, we all know”, “everyone knows that, so why waste time and money” – conflating personal anecdote with data…

    As I have mentioned in a couple of my posts here, I have encountered a significant number of colleagues (not just nurses) who will tell me that “research shows”, when it is an unevidenced assertion from a book or a very poorly designed and implemented study which cannot or should not show what is claimed.

    Until there is better training in critical thinking, how to read and critique research, research methods and then how to conduct research we will have great difficulty convincing anyone of anything.

  2. Hi Basket Press, thanks for commenting. I think it’s sadly true that nursing sometimes seems to have a lot of catching up to do in the critical thinking department.

    I have real concerns that the removal of the Safe Staffing brief from NICE was done hastily and without much forward planning about how the work was going to be carried on once it was handed over to NHSE. The result is that we are now in a kind of limbo with respect to Safe Staffing in a number of nursing disciplines, with no time table for when and how this situation will be resolved.

    On the other hand, I think that what the whole debacle has really illustrated is how little we really know about nursing. Work on Safe Staffing was, in a sense, not ready to be handed over to NICE for analysis because the research base was too weak to enable them to create anything credible out of it. In that sense, I agree with those who say the move away from NICE is a step backwards – but only because I think the truth may be that nursing is not yet at a stage to take, and to sustain the momentum of, a step forwards.

    Neither am I amongst those who argue that we should oppose the transfer of Safe Staffing development work to NHSE solely on the grounds that ‘it was a Francis recommendation’. In my opinion, Robert Francis, whilst undoubtedly well-intentioned, had a flawed understanding of nursing which is evident in many of his pronouncements about it. We have to be allowed to interrogate the Francis Report. While I do not dispute that the treatment of patients on some wards at Stafford Hospital was appalling, to treat the Francis recommendations as Sacred Cows which can never be wrong is yet another example of failure to think critically.

  3. Basket Press permalink

    Then link to the perception of NICE as independent of government and NHSE and the CNO as not independent of government and it is easy to see why many would be critical of this move.

    You don’t particularly have to subscribe to conspiracy theories: if I look at every director of nursing (the pool from which CNOs are mostly drawn) in every trust I’ve worked for they have risen to that post by being “yes people”. The one on my last trust was married to an former colleague and I had known them since we were both staff nurses and wasn’t that great at actual nursing but was good at networking and self-promotion. This person then presided over significant cuts to nursing numbers without any sign of protest.

    The pool from which CNOs are drawn does not fill me with anything approaching confidence.

    But I am a notorious cynic.

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