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Do not adjust your (mind)set

July 25, 2015

“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.

  1. ljbp permalink

    A really interesting read coming from someone that is currently training to be a nurse. It is still is a bit of a mystery to me what options there are for nurses when they qualify. For example, I have wondered whether it is more supported for nurses to progress managerially or academically. This blog gets it spot on though, any further education and development is all in favour of giving more to the patient. Thanks for a thought provoking read!

    • Hi ljpb, and thanks for commenting. I don’t know if you listened to the first episode of ‘Who Wants to be a Nurse?’, but one of the students interviewed there rather poignantly said that ‘no one really knows what a nurse is’, and it’s interesting that you seem to be echoing that.

      It’s also very sad to read that at a time of expanding opportunities for nurses, there is still confusion amongst undergraduates about what the profession has to offer. Unfortunately, career development has always been one of nursing’s many weak points, with many people looking back as they near retirement and realising that career-building was very much a DIY-activity, or even worse, simply a matter of being in the right place at the right time.

      Clearly this is not adequate, and can only result in frustration, disillusion and huge waste of talent. In the absence of anything more organised, my advice to any student is to find themselves a mentor – manager, practitioner, doesn’t matter as long as they are willing to take an interest in you and be honest about your strengths and weaknesses. Have a plan. If you just drift or leave it to fate, you risk ending up stuck for years in a job you don’t really like.

  2. RGN007 permalink

    But if an “educated person” does not have to not do menial tasks, neither should we assume that a non accredited but still educated person cannot challenge poor practice.

    I am not against degrees in nursing, but I am against creating a divide that assumes academic qualifications is the only route to using one’s brain productively. I am cheesed off with the institutional jumping through hoops nursing has created.

    I am not a high achiever in expressing what I know in exams, but I still independently have a degrees worth of nursing modules because I thought it was the way to learn where I identified gaps in knowledge. It did help, but because it did not follow a particular institutional proforma, most universities do not recognise each others variance on the same discipline.

    I believe nursing should itself accept more diversity that not all potential good nurses need to come from the same academic cardboard pot.
    What about those who read and update continuously but not from attending a formal course, yet apply what they learn to practice because they have that personality to care and drive improved care pathways but do not have resources, time, money or support from employers?

    • Hi RGN 007 and thanks for commenting. I think there may be a slight misunderstanding here in that my point was more that rather than believing that an educated person should not lower themselves to menial tasks, we should instead look at re-defining what is a menial task. No task is menial if it is important to the patient. That is the essence of patient-centred care.

      I thought Ruth’s boast that she can ‘just look at a patient and know whether they are ill or not ill’ was one of the most significant moments of the whole programme – although if they’re a patient, presumably they have already been categorised as ‘ill’ by someone, even if only by themselves; so let’s assume that what she actually meant was ‘deteriorating’. But we must ask ourselves: is ‘just looking’ at someone sufficient? Agreed, it may tell you a lot – but isn’t education in nursing supposed to get us away from mere taste and smell, and towards understanding and quantifying WHY the patient looks ill, so that we can take rapid action to reverse it?

      That we still have a long way to go with convincing the media of nurses’ potential was illustrated by this news item from last month: (the BBC again – someone really needs to have a word with them!). Note how the writer seems to think that now we’re in the early twenty-first century, it might just be acceptable for experienced nurses to occasionally ‘be assertive’ with junior doctors. The logical corollary is that for a junior nurse to have the temerity to frequently ‘be assertive’ with a consultant would be less palatable. But if patient safety or even patient preference is at stake, that is the mindset that should be unacceptable.

  3. RGN007 permalink

    (Chuckling)…yes…that is my point. I am bad in writing at explaining myself and did understand that the educated nurse should not think doing menial work is not part of patient care. It isn’t…yet I feel we have a paradox here. Menial is not degrading, it’s just we haven’t time to do everything the patient wants.

    Just read the article you linked to and I just happen to be a senior practice nurse that has felt frustrated and held back by the very view the medical profession refers to re professional protectionism. Working in general practice is particularly pertinent because in that field of nursing it is usually the GP’s who decide what the nursing role is as we don’t have nurse managers. Not only that, but as a “business”, GP partners do not have to conform to the NHS working conditions or pay, yet we look after NHS patients and use NHS nurses. I chose to access courses in my own time and expense because I wanted to use my head more.

    One “menial” example is taking blood. I don’t dislike doing it and it is more convenient for the patient, but it is not my choice of career, to sit taking blood throughout my day and using my appointments to do it takes away appointments for other skills I have developed.

    With limited appointments available, every time a patient books in for their convenience for something that needs less skill, it means there is an appointment fewer for the 90 or so diabetes patients who have to wait 4 weeks or longer for their appointment. Cannot have it both ways.
    If the GPs take back the management of diabetes because I have no time to do it, then I will not be actually doing the “advanced” skills I have taken the time and expense to train for and the part of the job that motivates me to stay.

  4. The question ‘what do we want our nurses to be?’ was posed by the presenter in both episodes of Who Wants to be a Nurse?, as if it is up to anyone but nurses themselves to provide the answer. I think the whole idea of basing nursing only on what patients want, while logical and appealing on one level, is in fact fraught with difficulty. As the programme made clear, what some patients (a minority perhaps, but still with a right to have their views heard) want from nurses is unreasonable and uninformed. Examples were given of patients demanding certain investigations even when they are not appropriate; and people with minor injuries who expect to be prioritised ahead those with life-threatening problems. Additionally, the popular press delights in informing us that the public does not want educated nurses.

    Maybe we would have more clarity if, after listening to the public’s views, we made our own decisions about where nursing is heading.

    How do you think your GP practice could resolve your problems with having all your time taken up with taking blood? Should they employ dedicated phlebotomists?

  5. RGN007 permalink

    Yes, the answer seems obvious in employing a phlebotomist, but also, what patients want is less inconvenience and only to come in to the surgery once…a “one stop” service. Again, lack of understanding by some patients who do not understand the point of a review is to discuss the results.
    Actually, in this case I did write to the (then) MP to complain about the standard of premises. Newly developed, but not enough space and very poor quality construction. I was furious (and stressed and disappointed) that the NHS funds had been blown on very poor design by an estate’s manager who then just changed jobs. Even my colleagues door jam fell off at one point!
    In effect then, we have no room for more staff to have a proper skill mix, and not only that, but the GP independent business owners have no obligation to even know what bands of nursing mean. I mean, would we buy a car and not know the size of the engine?

    I have a meeting soon to discuss skill mix, and to suggest an innovative way of working by taking the role out of the surgery and into the patients’ homes via iPad, but this means other staff members also have to be a little flexible, including myself , to have some accommodation for data transfer, ringing patients, organising one’s day etc. I might be getting listened to this time….I hope, but I still don’t think education has to come from a University, but self drive, motivation, passion. The degree is just icing on a cake but some nurses might just have a delicious filling without needing the topping.

    With regard to where nursing is heading, I think it is a mistake to aim for a one size fits all simply because we all have different aptitudes, abilities, perceptions, gut feelings, empathy, academic ability. We are all a continuum of all things so I like the idea of competences and experience as well as some accreditation. I don’t mean loose cannons firing everywhere, but in nursing we have such diversity within ourselves and often arrive in our speciality from different backgrounds and there is a reason for that. Take that choice and pathway away and some of us will lose the passion that drove us there in the first place.

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