Researching custom and practice

Researching a book is, as any author will tell you far more enjoyable than the actual writing of it. You can go off on all kinds of tangents and find out fascinating facts that may or most likely may never appear in your book. There is also the opportunity for  self indulgence and I have loved the chance to enage in a little reminisience of nurse training days.

In pursuit of insight and knowledge for Rituals and Myths in Nursing I recently visited two very different nursing museums at two prestigious London Hospitals. St Thomas’ Hospital’s Nightingale Museum gives you all the low down on Florence – some 3000 artefacts relating not just to her work in the Crimea and her drive to establish nursing as a respectable profession in the UK but also to her family and childhood. The museum opened in 1989 on the site of the original Nightingale Training School and, thanks to the diligence of matrons and others over the years much memorabilia has been saved for our interest and enjoyment now.

For me, the most fascinating Florence fact I learnt is just what an amazing architect/statistician Florence was. Never mind the nursing rules and regulations she set out in Notes on Nursing: What it is and what it is not. From her detailed scaled drawings of what was to become St Thomas’s hospital, down to the exact distance each bed on a ward should be from other for optimum health are something that should be heralded as truly ahead of her time.

St Bartholomew's Hospital Square

On the north side of the Thames overlooking the beautifully restored 18^th century square designed by James Gibbs at the Royal and Ancient Hospital of St Bartholomew is the Bart’s museum . Small but packed with medical and nursing artefacts, the Bart’s museum is more intimate than the more sophisticated Nightingale museum offering less about the broader history of nursing but imbued with the very essence of what it is to have been a part of the hospital at any time in its history. It is not just my personal allegiance to the hospital – once a Bart’s nurse always a Bart’s nurse – but there is a warmth to the exhibition that is welcoming and friendly.

St Bartholomew's the Less

Visiting a museum that is at the very heart of the hospital gives the visitor an opportunity to see other things. Top amongst the Bart’s exhibits are the two magnificent William Hogarth paintings which hang on the staircase to the Great Hall and can be spied from the museum. But for me it is the tiny chapel of St Bartholomews's the Less that is just a few steps from the muesum, with its stained glass window commenorating the work of nurses during the second world war that is particularly special. 

Inside the museum I rather like the intriguing notes and records of weird and wonderful operations, photographs and records of stern looking matrons – Miss Gordon Fenwick (later Mrs Bedford Fenwick) who successfully fought for nurse registration for instance - and mutton chop whiskered surgeons with grand names recognisable from the wards once named after them: Percival Pott, William Harvey, Thomas Vicary. It is also rather strange to realise that history can feel very recent. A friend of mine was startled to see a replica of the uniform she wore in the 1970s at St Thomas’s showcased as a historical artefact!

As we grow older, history comes into focus. We want to put a marker down for where we were in the passage of time recognising that some of what we see even in our lifetimes future generations will consider remarkable. Medical advancement over the last century has been phenomenal and while ritual and myth still exist in nursing, there is less that is ritualistic as the work is ever more evidence based and the role highly technical.

Nurses are still required to be all things to all patients but their level of technical expertise is greater than a generation ago. A requirement that has largely gone unrecognised by the public, the politicians and perhaps by some of the profession itself. The custom and practice of nursing is certainly changing.

Celebrating history; fighting for a future

Westminster Abbey was packed with nurses, many were in the superbly uniformed ranks of service men and women but there were also nurses from every civilian rank and file: care support workers through to the chief nursing officer for England, Professor Jane Cummings.  The woman next to me was limbering up with gentle humming under her breath, familiarising herself with the hymns in the service sheet. The ladies the other side of me and all around were chatting to each other and some were calling out as they spotted old friends. 

This was my first time at the annual service to commemorate the life of Florence Nightingale. Speak it quietly but I’ve never been a huge fan of Florence and have always felt she has been heralded in the public eye to the exclusion of some other pretty amazing nurse leaders (Mary Seacole, Edith Cavell, Ethel Bedford Fenwick, to name a few).  But, as I am writing a book on the Rituals and Myths in Nursing, I was intrigued to witness this ultimate ritual in the nursing calendar: the celebration of Florence’s life.

As you will know, Florence was known as the ‘the lady with the lamp’, during her work in Crimea, and a lamp is kept in the Florence Nightingale chapel (yes really) at Westminster Abbey. The lamp was carried in procession by a Florence Nightingale Foundation scholar Sandra Mononga and the Lamp party was escorted by student nurses and midwives from Edinburgh Napier University, dressed in white uniforms and hats. The ceremony involves a series of processions through the Abbey to celebrate nurses who have served and continue to serve. First off were the Chelsea Pensioners – taking part in memory of Florence and her care of the troops – their predecessors – during the Crimean Campaign. Honorary officers of the Florence Nightingale Foundation were followed by the masters and warden of the newly formed Guild of Nurses and after that were a stream of nurse representatives from the many and varied corners of nursing and the armed forces.

The service is supported by the Florence Nightingale Foundation (a ‘living memorial to Florence Nightingale’). The service is held as close as possible to 12^th May – Florence’s birthday and now International Nurses Day. This year there was a bit of a clash: for the ceremony was held on 17^th May which coincided with RCN congress, both huge events in the nursing calendar. The story has it that the RCN president, Cecilia Amin, had to hotfoot it down from Congress in Liverpool to attend the hour long ceremony at Westminster Abbey.

Of course there were more than enough nurses to go round for both events with plenty others still on duty. According to Statista the statistics portal, there are 675,000 nurses in the UK and that doesn’t, as far as I can ascertain, include the armed services. Yet, still wards and services are short staffed.

For me, the clash of dates brought into focus the very different facets of nursing and nurses. On the one hand at Congress nurses were fighting to be heard by politicians and public alike: concerns about pay restraint, loss of real term income, nursing bursaries and shortage of skilled nursing care in every aspect of the health service. Whilst at Westminster Abbey, nurses were celebrating the art and science of what makes nursing good, away from the daily grind of long hours and poor reward. 

Whilst Labour leader Jeremy Corbyn and Lib Dem leader Tim Farron appeared at Congress to promise the kind of basic improvements in pay and conditions that nurses are desperate to see, the Conservatives saw no point in being targets for metaphorical if not actual egg throwing. The Tories know that the public still does not grasp how poorly recompensed nurses are and that the power to change this and how the NHS is regarded lies with their vote. And perhaps even politicians could see the hypocrisy in attending an event to celebrate the very foundation of nursing when as leaders they appear so unconcerned for the profession's future?  

Nurses’ pay has been relentlessly held back. The 1% cap is eroding nurses’ pay now and in the future. It is the reason that nurses are using food banks, no more complex than that. This, together with an overall shortage of nurses, downgrading of posts, loss of the nursing bursary and a political failure to actually care, means we are headed to months of disruption and potential strike action amongst a dedicated long suffering workforce.  My guess is that the politicians will ride it out, just like they did with the junior doctors. Short term success, being the only show in town because that sets the scene for longer term demise of a service that people will only value once it has gone.

As the woman next to me in the Abbey launched into the first hymn with a deafening but fortunately, tuneful voice, I realized that in reality these two celebrations were one and the same: Congress being the current vociferous call for action protecting the ancient bedrock of nursing, the history of which was being celebrated in the Abbey, both reminding us of the values and commitment of nursing’s predecessors and the fight that is on for its future.

 

What goes around...

What goes around comes around. Never is this saying more true than when it comes to nurse training. When I trained  in the New Wave era of the 1980s, it was basically an apprenticeship as it had been for generations before me. Our training was fully funded. We worked on the wards and were paid a pittance because we knew nothing but we were a pair of hands - an increasingly useful pair as we progressed. We learned in modules in the classroom in between each placement. Alongside us on the wards were enrolled nurses - doing two years to our three for a 'lesser' qualification. And there were degree course students - doing four years - who spent more time studying and less time in the sluice but came out as registered nurses like us. I had friends in all nursing streams and while I was envious of the degree course nurses - with proper recognition for their academic work - I understood the intent of the enrolled nurses, many of whom just wanted to qualify as quickly as possible and hadn't understood when they applied that they would get a 'lesser' qualification.

Gradually the profession learnt the folly of having two tiers of qualification - some of the best nurses had an enrolled qualification but their careers were stymied - they couldn't progress. Many 'converted' via extra training to become registered nurses. From the turn of the century diploma and degree courses ran side by side with many people opting for a diploma course because they couldn't afford to do a degree. By 2013, nursing was a degree only profession. The move was of course accompanied by the usual moans about nurses not needing to be educated and educated nurses meant compassionless care. Education doesn't make someone a bad nurse, although overwork, poor pay and lack of managerial support can make compassion hard to find.

Nurses, together with some other professions allied to nursing - physiotherapists for instance but not paramedics - currently still have their training paid for via an NHS bursary but they are no longer paid to work. They are supernumerary to the numbers on the ward. Again this can be a blurred line - the more skilled they become the more appropriate it is to leave them to get on without hovering over them - but is that exploiting them?

And now, just two short years later in a move Chancellor George Osborne describes as 'modernising' the profession, the government has announced that nurses will pay £9,000 a year for the privilege of training. All for a job with a starting salary at band 5 (staff nurse) of £21,000, rising to the dizzy heights of around £28,000 some eight years later (If increments are still permitted). And the majority of nurses will stay at band 5.

Not everyone can progress to higher levels - much as the police force needs its constables, the NHS needs its staff nurses.  Added to which  there are  few jobs around at band 6 - many of these are ward manager posts, downgraded from band 7. The latter (with a starting salary of £31,000) is now vanishingly rare amongst the nursing profession.  For more on nursing pay rates visit the RCN site here.

So there is every chance a newly qualified nurse will earn just enough to have to start paying back her student loan and, with the threat that hangs over incremental pay (on the junior doctors' list of grievances) they may never earn even a modest pay rise. MPs got their 10% rise on the back of their independent pay review body but the equivalent pay review body for nurses recommending a 1% pay rise was turned down in 2014 by the health secretary as too expensive. A 1% rise was granted in 2015 but was hedged with freezes to incremental pay.

A nurse may never move beyond staff nurse  - in 40 years of nursing her (and it is 90% likely to be a 'her') pay will hardly rise. This will do nothing to close the gender pay gap already present between male and female graduates - with 20% of male graduates earning £30,000 or more compared to just 8% of women.

Throw in that most of the nursing workforce are women (did I mention that?) and that women are still the only ones biologically able to give birth so their chances of career progression and better pay will be curtailed or at best postponed for several years by childcare. And all the time they must make sure they remain up to date, complete sufficient clinical hours and pay an annual subscription of £120 to the Nursing and Midwifery Council (NMC).

One of the arguments for student loans was that graduates would earn more than those who didn't go to university. That argument is now redundant. True if degrees are in civil engineering or mathematics as this article in The Telegraph shows but nursing doesn't feature here. Graduates will earn on average £12,000 a year more than non-graduates entering the job market who can expect to earn around £22,000. Nursing graduates are below this on £21,000. And yet they will be paying the same level of tuition fees for their training as someone starting on £30,000.

Not like other students
The reason why there is a shortage of nurses is because NHS Trusts, scrapping to get their books in order so they could apply for Foundation status 'miscalculated' the number of nurses they would need. this translated into fewer training places and now future nurses will be paying a very heavy price for this mistake.

At the time of Osborne's announcement, chief executive of the RCN, Janet Davies said: “Student nurses shouldn’t be the ones having to pay for it. Student nurses aren’t like other students. Half of their time is spent in clinical practice working directly with patients and their families and they have a longer academic year.

Davies also said "The proposal could deter the sizeable number of student nurses already owing significant amounts from a previous degree, Davies warned. “The average age of students on nursing degree courses is 29. They’re not all 18-year-olds.”


But now the idea of 'nursing associates' is being sold as the answer to those who can't afford to pay for a degree. Back to two tiers of nursing. Badged as nursing apprenticeships and hedged with sentimental quotes about nurses being the 'lifeblood' of the NHS (despite being so badly paid) this is a sell out by the nursing hierarchy who have argued for so long for an all degree profession.

Find out how to respond to government plans to scrap the NHS bursary here and use the RCN's online calculator to work out just how far nursing salaries are lagging behind

Travel sick - banning smoking in cars

Queuing in traffic around the north circular on the way to relatives was a feature of my childhood. As was my mother's stress at the combination of the length of the journey and my father's nose to tail break hard driving. Her need for a cigarette was pretty overpowering. I remember my brothers and I pleading with both our (health professional) parents not to smoke in the car - something they heeded as best as nicotine addicts can. We had to have the windows wound up to shut out the smell of traffic fumes only to be locked in the car with cigarette fumes. It was only the very real threat of me throwing up due to aforesaid breaking that stopped my mother lighting up.

This experience was probably pretty common in the 1970s and increasingly less common in the decades since - although Labour and co-operative MP Luciana Berger claims here that one in five children may still be exposed to smoke in cars. Whether it is out of ignorance of the harm they do or denial in the face of addiction, only legislation will force parents to confront what they are risking.

It's hard to know why banning smoking in cars is such a contentious issue. Yet it's a real fight - one that may well go down to the wire - just like banning smoking in public places - but we got there in the end with that. We have to hope that this government doesn't once again run scared of legislation to protect the public's health just as it did with plain packaging of cigarettes and minimum unit pricing of alcohol - although it may be tiptoeing back to reconsider the latter.

The House of Lords has backed Labour's proposal to ban smoking in cars carrying children. Ministers are now looking at how to implement such a ban. Disappointingly, however, deputy prime minister Nick Clegg said on his weekly LBC phone in that he was opposed to legislation that would allow the government to ban smoking in cars with children - calling it 'sub contracting parenthood'. But then I hadn't realised that Clegg was a smoker. Does he think car seats for babies is 'sub contracting parenthood' or is it just the smoking thing? Read the story here
Read @COPDdoc Nick Hopkinson's excellent dissection of Clegg's arguments here


There is widespread evidence here and here that second hand smoke harms those who breathe it in. That this is so was a strong feature of the argument for banning smoking in public places - those employed in pubs and clubs were forced to breathe in the cigarette smoke of punters hour after hour. Five years after the public smoking ban, there were reports of improved health amongst barworkers and it has been almost universally welcomed by them and by their customers. Although there are still hardy knots of people gathered outside pubs and clubs sharing nicotine and camaradrie with other smokers.

It was thought that the ban on smoking in public places would drive smokers back into the home to light up. But it seems this didn't happen. Many smokers took the opportunity to give up whilst many more at least took their smoking outside just as they had to when in a public place.

Of course, public health education must continue to be a big part of changing smokers' habits, together with support to help people give up. But we know from experience that public health campaigns are most effective in changing behaviour when they are backed by legislation. That was the lesson from introducing the law on wearing seatbelts, and the drink driving and smoking bans.

Children, of course, have no say in any of this but if they had, I don't believe one would say 'I wish Mum or Dad would smoke in the car.'

Blowing a gasket

Politicians hijacked the family doctor label and used it to sell the changes in the NHS to an uncomprehending, trusting public. Now secretary of state for health, Jeremy Hunt wants family doctors back in their surgeries doing what they do best as well as running the night shift in order to keep people out of A&E. It’s not going to work.

As a nurse who trained under the old order in what was basically an apprenticeship as well as under the new order in a return to practice course, I felt ‘qualified’ to comment in my last post about nurses. I decried the idea that student nurses should spend a year working as healthcare assistants before being allowed to train as student nurses. 

A month later I find myself writing about GPs – they being the latest professionals under attack from the coalition government. My ‘qualification’ here is more third party. As the daughter of a GP and also the sister of one, I’ve plenty of experience of how the job affects family life and, having worked professionally with GPs, I feel I have an insight into their workload and, to a certain extent, what drives them. And, of course, being a patient gives me the shop window view.

I confess to more than a little hypocrisy, having complained myself about the curmudgeonly, recalcitrant nature that is at the core of many a GP (with no one being more recalcitrant than my late father who took things to another level). However, GPs having long been on a pedestal must now feel they can’t do right for doing wrong. Having been given the keys to the  commissioning purse as part of the Lansley changes to the health service thus distracting them from their day job, they are now being castigated for having given up their night role 10 years ago which apparently has only now started to affect A&E services. Speaking at the King’s Fund recently, Secretary of State Jeremy Hunt, told GPs to take responsibility for the care of their patients out of hours http://www.telegraph.co.uk/health/10077146/Jeremy-Hunt-orders-GPs-to-take-charge-of-out-of-hours-care-as-row-escalates.html

Hunt complains that we have lost sight of the concept of the family doctor. We? I think he means politicians lost sight of the family doctor when they appointed them as head honchos buying services for their patients instead of referring to them; making GPs responsible for the health of the local population when their skill lay in the clinical needs of the individual patient in front of them.

My local GP surgery, may not implement with gusto all the various public health measures that I think would be a great idea just because they are ‘ideally placed’ in the community but, when push comes to shove, they have always been on the side of the patient. They have provided excellent care to me and my family, expedited appointments and been fantastic support at times of need.

Much has been written about the problems with A&E: the rising numbers of patients being admitted via their doors and the long waits which we thought were a thing of the past. Statistics have been bandied about with a variety of commentators offering their views and reasons.  The pressures on A&E have undoubtedly been caused by a range of factors – a cut in the number of inpatient beds means people back up in A& E waiting for admission. The cuts to social care mean that people may not cope so well at home and seek admission to hospital and, with less support in the community, it is harder to discharge people from hospital.  The whole system is under pressure and the gasket is blowing in A&E.

When it comes to the arguments over A&E numbers, I found the King’s Fund’s John Appleby’s blog the most compelling argument for why numbers were increasing and why there’s no need to panic: http://www.kingsfund.org.uk/blog/2013/04/are-accident-and-emergency-attendances-increasing

His logic has to make you wonder; is the media storm over A&E nothing but a stirring of the hornet’s nest creating an impression of a ‘failing’ NHS that needs saving by the private sector? Hmmm, can’t see that working either. If there’s one thing that presents at the door of A&E it is ‘difficult’ patients and that’s one thing the private sector doesn’t want. ‘Difficult’ patients with complex social circumstances, co-morbidities and distressed relatives are time consuming and expensive. Paying for care at the entrance of A&E would truly be the end of 60 years of care free at the point of delivery. I wonder when that idea will be voiced?