When I Wasn’t There…

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When I wasn’t there, I hope you didn’t think I was not doing anything for your sick teenager, or something that didn’t indirectly contribute to his care.

When I wasn’t there, I was organising my other patients’ care around your son’s, because I knew he needed me the most. I was asking a colleague to cover another task that clashed, so I could continue to prioritise your son.

When I wasn’t there, I was sat at the desk with my calculator totaling up his complex fluids, to see where we were. Then I’m spending 20 minutes with the Registrar, discussing his disconcertingly negative fluid balance – it’s been like that for about 36 hours, and I knew it couldn’t continue. I ask to get a second Registrar’s opinion, and I involved the nurse in charge, before we decided anything. I could’ve just gone with the first doctor’s solution – it would be their prescription/decision, after all – so I could carry on with my long list of jobs. But I didn’t. Although it took time, I advocated for him until we got the right IV fluids prescribed and management plan in place.

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When I wasn’t there, I was hand writing two sides of A4 to document all that has been done. This is not just because it’s a legal requirement, but it’s so my colleagues have a detailed record of what’s happened.

When I wasn’t there, I was making midnight phone calls round all the other wards to find out if they have a medication that he needs which we didn’t stock, and then I ran off to get it myself.

When I wasn’t there, I was looking up the dose and preparation of two IV medications your son needed. I’d never given those drugs intravenously before, and I wanted to make certain there were no mistakes.

I wasn’t there all the time, or always straight away, I know. For that I’m genuinely sorry. I saw the pain in your eyes as your son grimaced and trembled in pain. I looked on as you struggled to answer your son when he questioned “Why me?” and “When will it stop?”. I watched every core of your being relentlessly aching as all you could do was put your arm round him. I saw how you couldn’t come to terms with the fact that all you can do is reassure him. Your nature is to care – you’re his mother. But this time the majority of care was in our hands and I know that was so hard for you. I saw your sleepless frustration at the IV pump that continuously alarmed disturbing your rest – I always responded as soon as I could.

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I hope you know that when I wasn’t there I was still thinking about both of you. And the next job for him, was already on my mind 30 minutes before it needed doing. I hurt with you both on those nights. I really cared, and I honestly did my level best. I hope it was enough.

Bursary or Bust? A Few Thoughts

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Following the Spending Review, NHS finances have again been scrutinised, and this time it’s monetary support given to healthcare students which attracted attention from George Osborne.

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To begin lets clarify one thing; the bursary isn’t being scrapped, but simply replaced by a loan. And for now this is only a proposal. Provided that the loan is equivalent to the NHS bursary (The loan structure has not been confirmed), I can’t foresee that the day to day living for student nurses will be affected.

The concern, however, is in the loan repayment and debt accumulation. This I can fully understand. If the system devised in the 2012 reforms was employed for student nurses, the graduate Band 5 nurse earning the salary of £21692, would only be required to repay £62.28 for the first year, and £111.24 in their second year (In accordance with the Agenda for Change pay scales).

While of course, finances can be tight for households, this isn’t a huge amount of money overall. Interestingly, this report on the course-wide 2012 reforms from the Institute of Fiscal Studies estimates that 75% of all graduates won’t earn enough to fully repay the loan, with an average of £30,000 debt being written off. I should think the majority of nurses will fall in that 75%.

If you’re a current or future student nurse you’re probably seething, because all I’ve said above implies I support this change. I don’t. I 110% believe that for the nature of the course, which doesn’t allow for part time jobs (Although many have no choice), nursing students fully deserve to have a financial support which is non-repayable. Maybe what I’m trying to point out now we’ve crunched some numbers, is that perhaps it isn’t as bad as it first seems.

Honestly, the proposal actually confuses me. Because with the cap on the number of places being removed, the government are likely to have to give even more money to student nurses – just now in the form of a loan. Yet we know thanks to our fiscal friends, that not much of this is actually repaid. So for all the administration and cost of changing systems, is there actually a saving worth making here? 37,000 applicants were rejected from a nursing degree in 2014, so I can’t see that the loan system will deter so many applicants that we start struggling for numbers. However, my concern is will the inevitable increase in student numbers decrease quality of training? Lecturers and approved practice mentors are hard to come by, and will the universities and practice areas be adequately supported for this increase? When any change is proposed to something so crucial like nurse education, questions such as these must be considered.

A final thought… I have been intrigued by the nursing community’s response to this news. I’ve seen videos of nurses chanting “Bursary or bust”, and much to my distaste the #nursesroar has been widely used. Every now and again, the old argument of whether nurses should be degree educated arises. For those who so vehemently argue we should be trained to graduate standard, I find it somewhat confusing that we then lower ourselves to chanting and (metaphorically) roaring. We are educated to evidence statements we make, and to think critically beyond face value of any information presented to us. If we want to keep the bursary, we need to make calm, articulate arguments against this, rather than reaching for our picket signs and megaphones.

The Shape of Caring Review & Nurse Education.

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Nurse education has just undergone widespread review, from Lord Willis. I actually agree with most of what he recommends (See page 63), however, I do believe that one of the fundamental root causes of the problems we have, has been overlooked.

We know that a system is only reviewed when its suitability is questioned or it is deemed insufficient. Over the last 40 years we’ve been through many different nurse education systems. Admittedly, Project 2000 was needed to keep up with the evolving nurse role. From that, we switched to the four field arrangement, and are probably changing our minds again. Whether we use a ‘four field’ or ‘generic’ structure (Though I favour the former), it seems we can’t find a ‘formula’ that meets expectations.

But we have never begun to consider that it might not actually be the structure or quality of education students receive that is the issue.

Before an applicant even applies, we expect them to have experience in relevant fields. However, it is near impossible for 16 & 17 year olds to gain significant hospital/care-based experience. Health Education England needs to work closely with local NHS Trusts and other care providers so we can (Through some arrangement) allow these teenagers to gain experience in these environments – safely and without compromising patients, of course – if that is something to be expected of them prior to applying.

When interviewing nursing degree applicants, they are in the “filter system” that essentially decides who can or can’t become a nurse*. Yet apart from the compulsory maths and English tests, no national standards exist which regulate interview formats or difficulty of the assessments.

Nurse education attrition rates are bad, with the national average sitting at 26.3% in 2006 (Estimated to have cost £98M), and drop out highs of 78% at one university in 2008. The national average for other undergraduate courses is 12.8%.

You’d think despite the additional demands, nursing would have lower attrition rates than degrees which do not include stringent admission procedures of interviews and assessments. Alas, this is not so.

To address the academic aspect, I believe we should standardise the assessment procedure and entry requirements. These all vary greatly, and a standard approach may create a more consistent student workforce.

Francis already hinted at value based recruitment, which I do strongly support. This is already in place in the form of group and/or 1-1 interviews. In addition to this, I would be interested to pilot using small OSCE assessments to show us how compassionately and effectively an applicant communicates with people. Simple simulation tasks could, for example, be assisting and reassuring a patient who is vomiting.

Policy appears to be slightly biased towards those who already have extensive clinical experience over the more traditional university student who comes straight from sixth form college with typically less knowledge. This bias I dislike because core nursing values, such as compassion (Which Francis called for an increased focus on), can still exist in young adults – and nurse education is simply there to model, nurture and encourage those values. The OSCE tasks I suggest might provide a better platform for all applicants to show their potential. We’re not looking for ready-made nurses at degree interviews, after all. When it comes to entering the register, we should all meet those standards, thus theoretically being at a very similar level.

Willis conforms to the aforementioned bias, by seeking to address undergraduate attrition by utilising clinical experience before training (He’s wanting care assistants to have APEL of up to 50% of the undergraduate nursing degree). However, many of the students who dropped out in my cohort already had plenty of experience, and it is mostly those with limited experience prior to training, that remain on the programme. I would be interested to know if this is the case across the country. If so, Willis’ ideas won’t work.

Nursing students drop out from courses for various reasons, from struggling academically to personal circumstances. I actually think an analysis of previous data to identify attrition ‘risk factors’ may prove more useful. If trends are identified, we can better support nursing students in danger of leaving due to either academic and/or personal circumstances.

We know nursing is heavily over-subscribed. So there’s enough people out there wanting to enter the profession. If we more carefully select students, I believe we would decrease attrition while improving quality – and all for not a huge amount of change or cost which some of Willis’ recommendations would involve.

*Though nursing students must meet the competencies for entry to the register outlined in the NMC Standards for Pre-Registration Nursing Education, there are very few, if any, who will make it to the registration phase at the end of the course to be told they do not meet the requirements. This makes the selection stage for training crucial.

How To Get An OpenAthens Account: For Healthcare Students

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OpenAthens offers a range of resources and access rights for those who have an NHS email account. I wasn’t given an NHS email account, yet I wanted to be able to access the BNFC on the Android App, which I have found very useful to have so quickly available to me. (The BNFC can also be accessed for free, online, here). Sometimes there are journals that are available through OpenAthens that I have found my university do not offer access to as well so it’s very benefical. Therefore here’s a quick ‘How to’, to help you. Here goes:

1. Go to: openathens.nice.org.uk
2. Tick the box to say you meet the eligibility criteria (You have to be on placement at the time, according to them)
3. Enter your university email address in the box
4. Complete the rest of the information the registering process requires. Note: Your account will not go through automatically, but an NHS account administrator will email you to confirm your position as a student.
5. The administrator will approve your account, and you’re away! You have an NHS OpenAthens account.

Like I say, this has been really useful to me, and it’s all free to access. Take advantage of it!

Best Wishes
Joel

What I Desperately Wish The Media Would Understand

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The media have an almost unbearably powerful influence on what the public thinks of our nation’s health services, and as many facts and figures they roll out, there’s often a failure to see things rationally from a ground level.

Nursing staffing shortages are well documented, and subsequently guidance has been published by NICE for adult inpatient wards, and draft guidance produced for A&E departments.

However, to solve the staffing shortages, is not as easy as the media appear to think. They seemed to think that the £700m cash injection given to A&Es in November would solve the staffing issues. As they state in that article: “It will help beef up staff numbers”. Yet while this funding is much appreciated I’m sure, I think how much it will solve the ongoing issue is questionable.

On a radio programme earlier this week, a presenter stated how nursing degree courses places have been decreasing – and how this obviously wasn’t helping the staffing situation. This clearly isn’t the case, as nursing places have now been increased by a further 4% for the 2015/2016 year, following a 6% increase the previous year. This is, as Dr Peter Carter describes it, a “Step in the right direction”.

What this presenter, and I think others, fail to understand is that universities make the number of spaces available partially based on the capacity that local health care services have for students to complete their placements on – and thinking logically, this cannot be changed quickly. We can’t expand hospitals and other services just to accommodate an increase of students. What we’ve got now, is what we’ve got for the foreseeable future. Therefore, 4% seems a reasonable figure, right?

Lets look at this rationally, and use a ‘case study’. My university uses two local DGHs for most of our clinical placements. The paediatric units at these hospitals can take roughly 7 students each, hence we started with a small cohort of just 13. Yes, we could have started with 20 or maybe even 30 or 40, but it would present logistical challenges in organising university rooms that are big enough, and be really difficult to sort out appropriate placements. It’s also crucial to remember that more students means a requirement for more approved mentors in practice settings.

So one of the route causes, is down to the number of nurses we can train. This is affected by the number of placement areas available, which cannot be changed quickly. Yes we must increase the number of places available, but this must be done sensibly, safely, and without compromising quality. And my plea to the media, is that they understand this. There’s no “quick fix” here. If the media understand this, then maybe the public will too.

Fully Informed Applicants?

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When I applied to university, I found there was a lack of information given to me. Despite my lovely personal tutor’s best efforts, my college had few links with local universities, and those already existent were weak, and not with the faculty I was applying to. There was a shortfall of information given about applying to the course, what I could do to increase my chances of being accepted, what the course was like and what being a children’s nurse really involves. And I’m pretty sure I’m not the only one who has had a similar experience to this.

So when the opportunity arose to be employed by my university on an ad-hoc basis to focus on running workshops, sessions, careers fairs and other events, about nursing courses, I of course, jumped at the chance.

I’m very (Warning: cliche word) passionate about what I do. I want college/sixth formers and mature students to have appropriate information about what nursing is, and how best they can apply. I love talking about it, I love enlightening them, answering their questions and giving them the best possible chance of being accepted.

Yeah that’s all great Joel, but why does it matter?

We know about the atrocious drop out rates that nursing has. We know that sometimes people enter into it, not fully informed, and then realise that nursing really isn’t for them and subsequently leave!

We also know that nursing degrees are heavily oversubscribed, and many students miss out on places. Students who could well have had the potential to become very good nurses.

By providing all the appropriate information to potential applicants, we ensure that the likelihood of them dropping out is decreased – as they are more informed about what they are entering into, and we ensure students who do want to apply have the best opportunities of being accepted.

What this ultimately comes down to, is the quality of the future nursing workforce, and the career choices of young people. Two things which are fundamentally important!

We would never expect a patient to undergo extensive or life changing surgery without being prepared properly or having all the relevant information about it, so why do we expect potential nursing students to make such a big life decision to come into the profession somewhat blinded?

5 Top Tips for New Student Nurses

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Welcome, new fresh-faced students, to the world of a nursing degree. I’m sure you are currently experiencing a plethora of emotions, from being beside yourself with excitement to just a little nervous about what lays ahead. Over the last 2 years, I’ve learnt a bit about the way to ride the waves that a nursing degree is. Here are my 5 top tips to help you:

1. Ask Questions/Make Comments
Early on, we’re understandably all a bit nervous but I encourage you to ask questions right from day one. Chances are, you won’t be the only one in the room with the same question. Be bold, stick your hand up, and engage with your fellow students and your lecturers. You get so much more out of a session if you engage with it, and why leave your mind in suspense?

2. Be Organised/Plan Ahead
This is difficult for some, I know. But find a way to organise yourself, be it an iPad app, or a physical academic diary, and utilise it. Allow it to organise your social life as well as your study life. Start thinking about your essays early on (Even if you work better under pressure), create assignment plans, get to know your reading lists, unit outcomes and so on. I also have a whiteboard in my kitchen where everything I need to remember goes. Personally, I’m a list maker. So do that if it works for you too. Time is unfortunately limited – there will only ever be 24 hours in a day, but if you’re organised, you’ve won half the battle.

3. Get to Know Your Physical & E-Libraries
In your first few weeks, you should receive an induction to your libraries. Once you’ve had this, make the effort to independently learn the system which the books are stacked in, and how to search for these in the online catalogs. Also learn how to use the e-library and effectively search for journals articles and the like. All the resources you need will be available to you. Understand how to find these, and you’ll be pulling in the top grades.

4. Look After Yourself
This I can’t stress enough. Taking time to look after yourself both physically and emotionally will have no end of benefits. Eat healthily, keep hydrated (Especially while on a shift) and taking time to exercise are all positive steps towards good physical health while you study. But, look after yourself mentally as well, by making sure you have a support network around you who you can trust and talk to if you’re struggling or experience a distressful situation. It may be beneficial to have a mix of people in and out of the nursing world – sometimes a bit of ‘normality’ can be really good.

5. Check Your Tunics Aren’t See-Through
Sooner or later, you’ll receive those much sought-after student nurse tunics! Especially if they’re white, make sure they aren’t see-through!!!! And get a white top or t-shirt to go underneath them if they are!

Hope these help you successfully kick-start your nursing degree. Any questions, don’t hesitate to ask!

All the best

Joel