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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.

Grief – five months on

I think it was somewhere around week thirteen that I stopped counting. It wasn’t conscious. But at some point I noticed that although it was a Thursday, I no longer knew, without looking at the calendar, exactly how many Thursdays had passed since that fateful one when he died. Does it mean I’m moving on? Or starting to forget?

I’ve stopped the useless going over and over the day it happened. The pity of it. What he said. What he meant. I don’t know if I don’t need to think about it any more, or if I’ve simply picked it dry. I suppose it’s another sign that inside my head, stuff is slowly shifting. What upsets me now are things like seeing his signature: casual signs that he was alive – alive! how for granted we took it! – and wanting, raging, offering to give anything, for that time to come back. How can it not come back?

To everyone who asked me (and there are an awful lot of you): yes, I am back at work now, thanks very much. I went back in the middle of April, as it goes, and I would have gone back sooner if my ninety-year-old father hadn’t taken sick after my husband’s funeral. But although I know you want to hear me say that work is helping (and to be honest, I sometimes wonder if ‘are you back at work?’ is just  code for ‘are you back to normal?’), it isn’t – or at least, not very much.

In ED I broke down one day. I’d only gone to collect a patient, but the last time I was there I was with Barry…the day he was admitted…sitting together…in one of those cubicles…and he was alive. I could touch him; I could talk to him; in that cubicle… And now he’s dead.

What floored me, I think, was the strangeness of him looming out at me in the middle of a working day. At home, I’m used to being surrounded by him – his books, his music, his model trains. I’m slowly divesting myself of all the stuff – if I’ve no use for them, I can see no sense in hanging on to things that could give others pleasure. But the things I can’t let go of – oddly perhaps – are not the ones he acquired during our life together, but those that pre-date it.

On the shelf, his Eagle Annual 1965 still sits, a present from Nanny, with fondest love. And amongst the many books on trains, the ones I can’t part with are the yearly ‘BR Locomotives and other Motive Power‘ series – late sixties and early seventies editions. To an outsider they look dull – laughable even: just lists of loco numbers interspersed with black-and-white shots of engines, maybe a carriage or two if you’re lucky. To me though, they’re full of him.

They accompanied him on his earliest adventures with his friends. The trains he spotted are proudly underlined in green biro, a permanent record of what he saw. One book contains a photo he actually took, of Class 451 750v d.c. 3-TIS unit No. 036. They speak to me of my husband in his purest form: an eager boy excited by life, and never thinking of death at all.

I haven’t got used to being alone. I haven’t got used to having to do everything, organise everything – every last little thing – myself, because if I don’t do it, no one will. I keep wondering when this will actually start to feel like my life, instead of someone else’s life that I’ve inexplicably taken over. Everything is too big for me now. My clothes – since I lost so much weight – the house, the garden. I’m walking around in a coat that no longer fits. Will I ever grow back into it?

Sometimes, I admit, I have wondered why I can’t just give it all up and go where he is. I want to be with him so much – but I know I can’t, at least not yet. All I can say is that when my own time does come – as come it must – I will approach without fear. If he died, so can I.

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.

Give the people what they want

Person-centred care is something I hear a lot about these days. As summarised in a helpful little booklet from the Health Foundation, it takes its cue from the idea that it is the relationship between patient and professional that lies at the heart of care. Crucially, that relationship should be one ‘in which health care professionals and patients work together to understand what is important to the person; make decisions about their care and treatment; identify and achieve their goals’ (p.8). Care, in other words, works outwards from what matters most to the one receiving it.

It’s been said that labelling your prejudices ‘common sense’ is just a user-friendly way of denying them. If that’s really the case, then here’s someone who’s happy to come clean right now: to me, person-centred care is a no-brainer. It’s such an obvious model that I don’t even know why we need to discuss it. A more natural question would be why on earth you wouldn’t start with what matters most to the patient?

One answer is vested interest. In the years after its creation, the NHS was accused of being the fiefdom of powerful professional groups – particularly medicine. But since the 1980s, (and with renewed urgency since the crash of 2008) the dominant political narrative has been that of the NHS as an inefficient and insatiable ‘bottomless pit’ that needs to be ‘capped’ by the introduction of competition, targets and efficiency savings. (Other interpretations are available. In a report produced last year by the respected Commonwealth Fund, the NHS sat at the top of the league of health care systems of developed nations, scoring highly on both efficiency and value for money).

For politicians of a certain stripe, constant portrayal of the NHS as something that needs to be ‘brought under control’ by containing costs, managing risk, demonstrating value for money and meeting targets is of course very convenient; it allows them to trumpet privatisation and the introduction of market economics as solutions to the ‘problem’. But, as well as giving impetus to a different sort of vested interest, this is also a narrative that seeps into, and profoundly affects, the health care professions. None more so than nursing.

Nursing occupies a position at the interface between patients and ‘the system’. Indeed, on a continuum with ‘person-centred care’ at one end and ‘system-centred care’ at the other, the place where nursing occurs could be seen as a bellwether of what really matters in the NHS. And for those who champion person-centred care, the signs are not good. With little resistance or debate, ward-based general nurses have become the de facto administrators of prevailing NHS philosophy.

By that I mean that – punctuated only by drugs round and the odd procedure – most nursing time is now spent responding to ever-more urgent management demands for accelerated ‘throughput management’, risk assessments (even though of unproven effectiveness), and page after page of documentation – with no thought to how formulaic or irrelevant much of it is, as long as it is done. To me, this situation bears all the hallmarks of a system that privileges the perpetuation of itself over the needs of those it is meant to serve.

Politicians would no doubt argue that my person-centred/system-centred continuum is actually a false dichotomy because patients are, by-and-large, also taxpayers, and as tax-payers, top of their agenda is value for money. Because of this, it becomes possible to paint the pursuit of value for money as a kind of person-centred-care. Examples of this can be seen in Jeremy Hunt’s recent pronouncements about the agency spend (‘It’s outrageous that taxpayers are being taken for a ride…’) and prescription drugs (‘this will…remind people of the cost of medicine’).

Clearly, it’s a definition that’s a long way from the one proposed the Health Foundation, but the government appears to have taken its recent victory at the polls as confirmation that it is the one the electorate prefers. Recognition of this would certainly go a long way towards explaining post-election decisions such at the axing of the NICE Safe Staffing Committee.

Trapped within the implacable logic of this new orthodoxy, the prospects for vast swathes of are caught in a double bind. On the one hand, adherence to the model of person-centred care proposed by the likes of the Health Foundation is now entirely dependent on the morality and courage of individual nurses and nurse managers; it is almost a subversive act. On the other hand, meanwhile, individuals who are perceived not to be giving nice, warm, person-centred care – to which lip-service continues to be paid – will be seen as personally culpable.

In this bleak picture, I suppose it’s some comfort to remember that not everyone comes out a loser. Jeremy Hunt at least can draw comfort from knowing that he’s given people what they want.