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Wednesday, February 28, 2024
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Something rotten in the state of nursing

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I AM a nurse, so I have some insight into what the job takes. I was a staff nurse, charge nurse and night superintendent (essentially a male matron). I have taught nurses at university level for nearly 40 years. I firmly believe in university-level education for nurses and have no time for arguments that everything was better before nursing became a university subject. I recall as a student nurse horrific pressure injuries and older people strapped to their chairs with sheets knotted behind them in geriatric wards and other abuse of patients in mental hospitals (which I reported) at levels which simply do not occur now.

I don’t discount the possibility that there are problems with the degree programmes. Clearly, whatever problems we are having in nursing, they are not solving them. But it is a common myth that nursing students at university do less clinical practice than they did under hospital training. They used to spend 50 per cent of their time in practice and this remains the minimum requirement. The accompanying myth is that university-educated nurses are taught only theory and the technical aspects of nursing as opposed to ‘caring’ skills. Again, this is not true, and a great deal of effort (some of it admittedly remedial) is dedicated to developing interpersonal skills. Attitude is one of the factors on which we ask clinical staff to assess our students.

Studies in the US and Europe consistently demonstrate better outcomes for patients in terms of survival when they are cared for by graduate as opposed to non-graduate nurses. Work at the University of Pennsylvania showed that higher levels of graduate nurses led to less failure to rescue in medical emergencies. This work led the Institute of Medicine in the US to recommend an increase in the number of graduate nurses. Notably the work is transferable as demonstrated by the Lancet’s most highly cited article of 2014 (which I had the privilege of reviewing for the journal) showing in a study of over 400,000 patients in 300 hospitals across Europe that the higher the number of graduate nurses, the more likely a patient was to survive a stay in hospital. I have contributed to this work through my involvement in a study in the Middle East which made a direct link between individual graduate versus non-graduate nurses and patient survival in hospital demonstrating the same relationship.

Yet something is wrong in the state of nursing, and I have both first-hand experience and anecdotal evidence by the busload to support this. I recall visiting my dying father a few years ago back in the hospital group in Scotland where I used to work. A whole visiting hour went past, and we never saw a nurse. But they seemed to be having a right laugh at the nurses’ station. Loath as I am to say that it was all better when I was a charge nurse, I am going to say it. Neither myself nor my opposite number would have tolerated it. We would have chased them away from the desk and told them to go and speak to the relatives and find out if there was anything they or the patients needed. The problem on that occasion seemed to be that nobody was in charge.

I grew used, in my final years as a nursing academic, to being embarrassed at the appearance of many of our students as they skulked about the campus, plumes of smoke wreathing their luridly dyed hair but, mercifully, blurring out their equally lurid tattoos and face piercings. The way they filled their uniforms was a constant source of comment and more than one vice-chancellor at more than one university has remarked to me at graduations about the prominence of obesity among nursing students, as yet another batch bounced across the stage to receive their scrolls.

Which brings me right up to date, this week in fact. Probably induced by a combination of radiating and acute lower back pain and some strong self-prescribed painkillers I passed out, white as a sheet, sweating profusely, gibbering nonsense and with an imperceptible blood pressure as monitored by my wife. A classic ‘vasovagal’ incident. My daughter, a critical-care specialist nurse practitioner, was on the scene in minutes and was convinced that her inheritance had come early. A 999 call was duly made, and the fun began.

The ambulance technicians who arrived were wonderful. They were reassuring to my wife, respectful of my daughter’s input to proceedings and quickly ran a few tests that revealed a minor conduction problem in my heart. They kept me fully informed throughout and quickly got me to the ambulance and the Emergency Department. They asked about my work and took a great deal of interest in me and kept my wife distracted from the corpse-like figure beside her.

We had a short wait accompanied by the ambulance crew throughout. The Filipino triage nurse was excellent as was the phlebotomy and ECG technician and after a while I was off to my own room. I was left alone for an hour by my wife as she went for something to eat with my daughter and, during that time, was entertained by the nurses sitting just outside my room cackling and laughing as they showed each other their Christmas photographs and videos. ‘That’s me there’, I heard a few times. Nice, but nobody looked in my direction once and when my wife and daughter returned, there was only one seat. My daughter had to stand for hours. Finally, it was the porter who took me to X-ray who fetched a chair for my daughter. Again, it seemed that nobody was in charge of the nurses; not a single one of them would have been sitting there had I been in charge.

The X-ray staff were polite and efficient, and a very nice female porter whisked me back to the room, chatting all the way. The young consultant, who had already visited and who kept checking to see if I had been to X-ray, was nothing less than superb. Polite, direct, caring and with lots of questions and explanations for me and giving me plenty of opportunity to ask mine. In the meantime my GP, who was aware that I’d had a ‘funny turn’ as my wife had phoned the surgery first, called my wife to see how I was. Incredible. The consultant even went to fetch some painkillers for me, something I should have had within a minute of arriving and then, before we left, fetched some further medication for me to take home. These are nursing tasks.

Other than triage, we had only one other encounter with a nurse, who squeezed herself into the room with difficulty, customary tattoos on display and told me that she was my nurse (after about four hours of being there) but that she was going home in two hours, said with a sigh of relief. She asked a couple of cursory questions, measured my blood pressure and disappeared. We never set eyes on her again.

It is a popular view that since nurses went to university it has all gone to hell in the proverbial handcart. But significant changes took place concomitantly in the NHS. One of these was the disappearance of a single figure, the matron, whose main responsibility was to walk the corridors and maintain standards. The Salmon Report of 1967 abolished the role of matron and distributed the responsibilities across several tiers of nursing managers. Thus, a task which had been someone’s became everyone’s, thereby becoming nobody’s. 

There are other issues, however. The role of matron was reflected in the roles of ward sisters and charge nurses who were also responsible for standards in their own areas. These roles remain but the job is simply not being done. There is something wrong with the raw material that is coming in to the profession, as exemplified by the obesity, tattoos and face piercings.

My own explanation, about which I have written and which has earned me great unpopularity in the profession, is the payment of bursaries to nursing students above the level available to any other university students. Anecdotes abound about people applying for nursing programmes simply for the bursary and the guarantee of a job at the end.

I am reluctant to refer to nursing as a ‘calling’ as I know many of no faith or sense of calling who are excellent nurses. But nursing is most definitely humanitarian work. It is and always has been more than ‘just a job’.

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Roger Watson
Roger Watson
Roger Watson is a Professor of Nursing.

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