Saturday, 29 January 2011

Back to nursing

Having trained as a general nurse in 1981, I think that these, by now, rather rusty skills, will now come in handy when I am in Ethiopia. So I am getting myself back on the nursing register. Foolishly, I thought that my nursing days were over and so didn't maintain my registration. My advice to anyone thinking of not paying that annual fee to the NMC is "you never know what you might end up doing, so keep your registration going". In order to get my PIN back I have to do at least 75 hours in practice, be signed off as competent in a variety of things, attend a University 'Return to Practice' course and finally pass the academic assessments. Perhaps it doesn't sound like much - after all, you might say, you have to think about patient safety - however, trying to do this whilst holding down a full-time job and planning a trip to Ethiopia is a skilled juggling act. Sometimes those balls come tumbling down.

So yesterday I did my 2nd shift on the ward after a 15 year break away from any hands-on clinical work. A few things strike me about nursing in 2011:
1) There seem to be a lot of 'specialist nurses', who presumably have quite tightly defined roles in looking after things like 'tissue viability', 'stomas', 'manual handling' etc etc. I want to avoid saying 'when I was nursing..... or in my days.....' but just can't resist. So, when I was nursing, 3 years of what I believe was excellent training, equipped me for total patient care. We were trained in numerous skills (including wound care, stoma care and how to 'handle' patients) and had a professional duty to update those skills. Actually, it wasn't so much of a professional duty, although clearly that was important, but we were interested in keeping up-to-date. Being a nurse was something to be proud of and we wanted to make sure that we did a good job.
It is also apparent to me that there is now a  team division; into specialist and generalist nurses. The generalists work shift hours and provide the day-today care, whereas the specialists work 9-5 and float between several wards. Of great surprise to me was the subtle shift to specialists writing their reports in the medical patient notes. Who are they writing their reports for? Are they supposed to be working with the general nurses to improve patient care? If so, why aren't their reports filed alongside the nursing reports? Of great amusement was the specialists nurse's note that said she carried out a wound care procedure under the supervision of a Foundation 1 year trainee doctor. Isn't the specialist nurse supposed to be the expert?

I'm sure that the specialist nurses provide just that - specialist care - but I can't help wondering whether this shift to specialism has not only created an unhelpful division in nursing, but has also left the general nurse de-skilled in certain areas. Patients are whole people and need to be cared for as whole people. Surely this includes their wounds, pressure areas and stomas?

2) Despite the increasing number of specialist nurses, very little has actually changed in the delivery of care. Increasing technology has meant that the many policies and procedures that dictate how every procedure needs to be carried out, can be accessed from the hospital intranet at the click of a button. I haven't actually seen anyone accessing these policies and procedures but presumably they will when they need to.......
One advantage of having such detailed and prescribed care is that nurses are not spending their time writing out pages of care plans - they just print one of the standard care plans off. So they don't even need to think about the care plan. And that's the point. They don't have to, and it seems to me, often don't , stop to think about the plan of care. Now maybe they are just all very aware of what care the patient needs and so don't need to refer to any notes. If they did look at the care plans, they are likely to find that they are very out of date - often being put there when the patient was admitted but never really looked at again.

3) I have been struck by the amount of time that qualified nurses spend on doing things that less qualified people could easily do. Why are nurses filling up the empty boxes of gloves, aprons etc etc, making fresh breakfast to replace the old one left to go cold on the side, cleaning bed areas, and taking dirty laundry and rubbish out? These are just a few things that a qualified nurse spends the day doing.

4) The nursing 'culture' is alive and well. Similarly to doctors who it has been shown learn how to be a doctor (culturised into the role), nurses also learn the culture of nursing. Having had such a long break away form nursing and spent this time in a different culture - the academic culture - it is enjoyable and almost comforting to dip back into the nursing culture.

So as you might guess, my return to practice is full of challenges, but I am thoroughly enjoying these. Thankfully, the nurses on my course and on the ward I am working on are all fantastic and very supportive - this is definitely something I have missed having left nursing all those years ago.

My question now is how different is nursing care in the UK to that provided in Ethiopia?

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