Becoming a Nurse

Fundamentals of Professional Practice for Nursing

Derek Sellman, Paul Snelling, Derek Sellman, Paul Snelling

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317436294
• Edition: 2
• Topic: Medicine
• Subtopic: Nursing Skills

The guidelines and skills required to become a nurse are always changing and it can be difficult to stay up-to-date with the current standards. This book has been specifically designed to address the main skills you need to meet NMC requirements.

Becoming a Nurse will demystify what you need to know while preparing you to meet NMC standards and become a confident, practising professional. The book introduces the many subjects outside the biological which are none the less essential for both pre-registration and practising nurses. This new edition has been thoroughly updated throughout, and includes four new chapters on psychosocial concepts for nursing; sociological concepts for nursing; spiritual care; and preceptorship and transition. Like the previous edition the book also covers:

Law, ethics and policy

Management and leadership

Communication, interpersonal skills and interprofessional working

Evidence based practice

Medicines management

Public health

and professional development

Each chapter is packed full of case studies, discussion question and further readings to encourage critical thinking and reflection. It is an excellent resource to prepare you for your programme or to refresh your knowledge of NMC standards.

1
INTRODUCTION

The state of UK nursing

Paul Snelling and Derek Sellman

Introduction

Keeping abreast of developments in the environment in which nursing has to practise can be very difficult. As editors of a textbook we are acutely aware of how quickly things go out of date, and so how unwise it might seem even to attempt to write an introductory chapter about contemporary nursing practice. Looking back to 2009 when the first edition of this book was published, we can see how much things have changed. The introductory section was finished on New Year’s Day in 2009 at a time when the global economic crisis was in full swing, with vast sums of money being printed and given to the banks. But as anyone who gets a loan will tell you, it’s only when you have to start paying it back that the consequences become real.

The first edition pre-dated the general election of 2010, which returned, for the first time in many years, no overall majority, and 5 years of Conservative/Liberal Democrat coalition government followed which presided over a strategy to reduce the budgetary deficit prioritising austerity. Even though it was claimed that the health budget would be protected, in reality the spending power of the budget was reduced because costs increase at a higher rate than ‘protected’ funds. In 2015 the Conservative Party was returned to power and austerity is set to continue for this parliament. Not only does this mean that pay restraint, which has seen the salaries of public servants including most nurses reduce significantly in real terms, seems likely to continue, but the financial climate and changing patterns of disease will continue to pressurise core services of the NHS and other care services. The professional practice of nurses and other health care professionals will inevitably be undertaken in this extremely challenging financial environment for the foreseeable future.

The other major development in the time since the first edition is the publication of the two Francis Reports into the events at Mid-Staffordshire Foundation NHS Trust. (The name of the hospital was Stafford Hospital, and often is abbreviated to ‘Mid-Staffs’). These reports investigated a catalogue of poor care, which may have resulted in the deaths of many patients. The alarm bells were rung by statistical data, which showed that more deaths than might have been expected occurred. The inquiry reports were published in 2010 and 2013, and their findings and subsequent responses from a range of bodies continue to have a profound effect on professional practice. This is a common theme running through this book. Politics on a grand scale is important of course, but not everyone is interested in Westminster debates and machinations. However, the results of financial squeezing and the renewed (perhaps rhetorical) emphasis on patient safety constitute a tension between cost and quality, which constrains every nurse’s practice. This introductory chapter introduces recent developments in the professional practice of nursing and nursing education.

The Events at Mid-Staffordshire Foundation NHS Trust

The events at Mid-Staffordshire Foundation NHS Trust were seminal in the development of health care policy and the professional practice of nursing. In 2007, concerns were raised about mortality rates at the Trust when compared with other similar hospitals. Despite the hospital being rated as ‘good to fair’ in the Healthcare Commission’s annual check, the Dr Foster guide showed that the Trust had a higher than average Hospital Standardised Mortality Ratio (HSMR – see Box 1.1). The Healthcare Commission, the regulator at the time, considered the response of the Trust to the high mortality to be inadequate and launched an investigation (Healthcare Commission 2009), which was critical of the Trust.

At about the same time public anger about the care delivered at the hospital grew, co-ordinated by a group called Cure the NHS (Bailey 2012), set up by Julie Bailey, whose mother died in Stafford Hospital. Ms Bailey, who was subsequently awarded a CBE in 2014, and her group became influential and vociferous, and the press maintained a keen interest. Cure the NHS pressed for a full public inquiry into the Trust’s failing and the wider NHS. Further reviews were commissioned on specific aspects of the care at Mid-Staffs, but none satisfied public concerns. Still there was to be no full public inquiry, but the Labour Government decided to set up an Independent Inquiry under the chairmanship of Robert Francis QC, as he then was (he became Sir Robert Francis in 2014). The two-volume report was published in February 2010. This report is sometimes referred to as the first Francis Report (Francis 2010) and its findings were wide ranging. The picture painted was of a failing yet complacent organisation, with poor leadership and where the focus of activity was directed at financial control rather than clinical outcomes. Nursing staff were noted to be demoralised and ‘many had adopted a survival strategy of going through the motions of doing their job as opposed to pursuing a much valued and necessary vocation’ (Francis 2010, p. 412). The letter from Mr Francis to the Secretary of State, which introduced the report, concluded that:

If there is one lesson to be learnt, I suggest that it is that people must always come before numbers. It is the individual experiences that lie behind statistics and benchmarks and action plans that really matter, and that is what must never be forgotten when policies are being made and implemented.

(Francis 2010, p. 4)

The Inquiry reported 3 months before the general election of 2010, and the incoming coalition Government agreed to hold a full public inquiry. As the name implies evidence

Box 1.1 Hospital Standardised Mortality Ratio (HSMR) and other statistics

The HSMR is a statistical test that is increasingly being used as an indicator of quality in hospitals. It compares actual recorded deaths with the number of deaths that are statistically predicted for the population served, controlled for factors such as deprivation and age. Where the number of deaths are exactly as expected, the ratio is 100. So, under a hundred is better than expected and over 100 is worse. Information about mortality statistics is published in annual guides like the Dr Foster Hospital Guide and also on the NHS Choices website. In 2007 the number was 127 at Stafford Hospital.

There are problems associated with these statistics. They depend on widely available data and the way that this data is coded can affect the results. A review article by Bottle et al. (2011) gives further details. The statistics have a role to play in identifying potential issues at hospitals, which can then be investigated further. This is what happened in 2013 when Dr Bruce Keogh investigated patient safety at number of trusts identified by high death rates (Keogh 2013).

Perhaps the biggest problem with these statistics is not how they are calculated but how they are used. The number of ‘excess’ deaths can be calculated but this is not the same as saying that this number of individuals died as a result of poor care. Sometimes people not schooled in statistical tests can confuse these two things, but there is also a suspicion that the figures are being deliberately misrepresented. For example, in reporting the findings of the Keogh Report the Daily Telegraph ran the headline ‘13,000 died needlessly at 14 worst NHS trusts’ (Donnelly and Saweer 2013). The Press Complaints Commission subsequently upheld a complaint about the headlines and the online version of the article carries a clarification at the bottom. But the headline remains the same. Spiegelhalter (2013) explains how the statistics are misrepresented.

More recently, similar arguments about statistics and their misrepresentation have been heard in debates discussing proposed reform to junior doctors’ contracts, with claims that there are 6,000–11,000 excess deaths per year at weekends hotly disputed by doctors and academics.

given to this inquiry was given in public, and the terms of reference were wider. This time Mr Francis was also asked to consider wider questions of NHS governance, that is how systems failed to notice what was going on and stop it sooner, and so the second Francis Report was more detailed. Mr Francis started his inquiry in November 2010 and published his three-volume report in February 2013 (Francis 2013). A whole chapter, chapter 23 in the third volume, is devoted to nursing containing 29 of the report’s 290 recommendations. The introduction to the nursing chapter reported as follows:

23.3 A very significant proportion of the complaints of poor care which the first inquiry and this inquiry have been concerned about have been due to poor nursing and it will be necessary to examine the causes of this. They include:

• inadequate staffing;
• poor leadership;
• poor recruitment;
• deficiencies in initial and continuing training;
• undervaluing the nursing task and those who perform it;
• declining professionalism.

23.4 It is clear that the nursing issues found in Stafford are not confined to the hospital but are found throughout the country. This is not to deny that much high-quality committed and compassionate nursing is carried out day in and day out, often with inadequate recognition. However, all in the profession must surely recognise that the challenges to the maintenance of proper standards and protection of patients have never been greater.

23.5 Until this scandalous decline in standards is reversed, it is likely that unacceptable levels of care will persist and therefore it is an area requiring the highest priority. There is no excuse for not tackling it successfully. Much of what needs to be done does not require additional resources, but changes in attitudes, culture, values and behaviour.

(Francis 2013, pp. 1498–1499)

This is damning criticism indeed, especially perhaps the observation that it was clear that the nursing issues are found throughout the country. The initial chapter of the report discussed the extent to which events described at Mid-Staffs and the explanations for them could be extrapolated more widely. Concerns that the inquiry was making too much of the evidence in a single organisation, which could not be interpreted more widely came from individuals and organisations that were pre-warned via letter that they were facing criticism in the final report. Though some patients asked him to, Mr Francis did not look elsewhere at other trusts because his terms of reference did not allow it, but he made three points to those who claimed too much extrapolation.

First, even if it was the case that there was no other provider as bad as Mid-Staffs, it was of concern that the systems of checks and balances didn’t work there. Second, there were a number of other publications at about the same time, for example, the Care Quality Commission (2013), the Alzheimer’s Society (2009) and the Patient’s Association (2009), which raised general concerns about the state of care in hospitals. Third, he said that the failure to detect the shortcomings of the Trust resulted in it being unlikely that the public had confidence that ‘another Stafford’ doesn’t exist.

It is debateable whether these three points are sufficient to enable the conclusion that the nursing issues highlighted can be ‘found throughout the country’ or that the recommendations presented in relation to nursing can be derived from the evidence presented in relation to the care at Mid-Staffs. The recommendations concerning nursing cover a good deal of ground and so won’t be reproduced here in their entirety. However there were some important themes addressed by further reports and actions, which continue to shape the nursing environment and are worth further consideration.

Nursing Education

The Willis Commission

In 2012 the Royal College of Nursing (RCN) commissioned Lord Willis to answer this question:

What essential features of preregistration nursing education in the UK, and what types of support for newly registered practitioners, are needed to create and maintain a workforce of competent, compassionate nurses fit to deliver future health and social care services?

(Willis 2012, p. 4)

Lord Willis sat with a panel of seven senior nurses, managers and academics. It found that:

The commission found no evidence of any major shortcomings in nursing education that could be held directly responsible for poor practice. It also found it difficult to prove or disprove the perception of a decline in standards of care.

(Willis 2012, p. 43)

The report was supportive of graduate preparation of nurses, which was agreed in 2009 and implemented by 2013, but met with some opposition especially in the national press (Gillette 2012, 2014). Without being overly sceptical, it is worthwhile when reading these reports to bear in mind the function and purpose of the sponsoring organisation, in this case the RCN, which has a mandate to advocate for nurses. Box 1.2 provides details about the types of organisations representing nurses or more concerned with nursing.

Raising the bar: the Shape of Caring Review

A later and more significant review of nurse education was also chaired by Lord Willis. Entitled the Shape of Caring Review, it was commissioned by Health Education England and the Nursing and Midwifery Council. Health Education England is the part of the Department of Health responsible for commissioning education; a review jointly commissioned by government and regulator must be considered a very authoritative source. The report made a number of recommendations, including about the role of health care assistants, building on the earlier Cavendish Review (Cavendish 2013), and the future shape of pre-registration nursing education.

Unregulated ‘nursing’ roles

There are nearly as many health care assistants as registered nurses working in the National Health Service. Within Europe, the UK, Ireland and Switzerland are the only countries where health care assistants are not regulated (Willis 2015) and currently there is no standardisation of training or titles. Following the Cavendish Review, a care certificate was introduced from April 2015 (NHS Employers 2015). As well as recommending evaluation and making the certificate mandatory, the Shape of Caring Review recommended that Health Education England should explore the possibility of creating a ‘defined care role’ (NHS Agenda for Change Band 3) that would act as a bridge between the unregulated care assistant workforce and the registered nursing workforce. As the report noted, assistant practitioners have been around for a number of years, but have never become widespread. As we write this introductory chapter, a consultation exercise is underway and by the time the book appears in print we will know more about the role: its title, level of education, whether it will be regul...