I originally published a post on the LCP in November 2012 before the independant review was announced
[Guest post by Connor Kinsella]
At great risk to the reputation what has always been one of the more respected organs of the health and social care blogosphere, I’ve been invited to contribute to the Not So Big Society blog. This may turn out to be about as welcome as a knighthood for Piers Morgan, but before I outstay my welcome I want to draw attention to an issue which, in public at least, remains remarkably under-discussed. It’s more than just the Elephant in the Room. It’s a bloody great dinosaur crouching on the mantelpiece belching loudly while everyone sits on the sofa wondering what’s happened to Patch the family Labrador.
I come to this subject on the back of a previous NSBS post. In Nursing Degrees aren’t the Problem, Zarathustra looks at poor care and the perceived erosion of compassion within the nursing profession, often attributed to the elevation of nurse training to degree and diploma level. The ‘too posh to wash’ argument is, as Zarathustra points out, thoroughly flawed on a number of counts, but one highly significant issue raised in the piece is the seeming impotence of practice tutors, mentors and academic supervisors to weed out the sort of students who really shouldn’t be let loose on an ant farm let alone caring for the sick and the vulnerable.
Failures in care can and do arise from the sort of systemic factors highlighted so ably by this blog among many others. Poor or non-existent resources, savage cuts and the sort of target-obsessed management twonks who punctuate every other sentence with ‘going forward’ are never going to further the cause of good quality care. But many years of mental health nursing and social care training delivery have left what is (to me at least) one undeniable conclusion. There are far too many individual workers who are simply not up to the task of working professionally and appropriately with vulnerable people.
And I’m not talking about the headline makers: the Shipmans and Allitts, nor the ‘care’ staff of Winterbourne View. I’m looking toward the day-to-day awfulness of the sort of workers who, as Zarathustra points out, could and should have been rooted out at an early stage long before they have gone on to cause misery to every patient, client, service user and colleague that has the misfortune to cross their path.
If you’re reading this as a health and social care professional, you probably know who they are. The ones who attract enough complaint letters to wallpaper a small room. The ones who know better than decades of random-controlled trials and decide that the holistic tree-bark infusion they read about on the internet is so-oooo much better at treating depression than “any of that CBT and medication nonsense.” The ones who think of clinical supervision as a) a tool of Satan or b) a personal affront to their professionalism and years of experience. And the ones who seem to think communication skills are the ability to post snaps of their buttocks on Facebook but who can talk to neither colleague nor service user without causing them to run sobbing to the nearest cupboard.
In the first (and ultimately overlong) draft of this post I embarked on a trip down memory lane to describe my fantastically dysfunctional intake of student Registered Mental Nurses way back in the early 1980s. This was as ghastly a bunch of ne’er do wells, inadequates, love addicts, perverts, substance misusers and pure textbook psychopaths as were ever let loose on the mentally ill.
But this was a skewed sample. The old institutions of the sort where old-timers like me first cut our mental health teeth were replete with flawed characters, and my cohort of student drama queens and underwear sniffers (yes, really) went barely noticed among the general monstrosity of a Victorian asylum. But as time went on and my clinical and training career took me to all corners of the health and social care universe, I really did begin to wonder what it is about this most demanding of fields that attracts so many unsuitable staff. Whether it’s damaged people seeking self-help, taking solace in working with those even more fragile than themselves or (more worryingly) meeting a need for power and control over society’s most vulnerable, this is perhaps a research study yet to be carried out. For even the power of Athens and Google fails to yield much in the way of answers.
Not that having the odd psychological peccadillo is always a harbinger of bad care. Some I have worked with have used difficult life experiences to very appropriate and professional effect without compromising those professional boundaries which are so often crossed by the wayward.
This is where we return to Zarathustra’s post. In particular a paper cited there (forgive the repetition) which I read at the author’s recommendation and can highly recommend again to anyone reading this, particularly if you have any responsibility for mentoring or supervising students, probationers or junior staff.
Kathleen Duffy’s 2003 Failure to Fail paper is the ‘go to’ qualitative study of factors influencing the assessment of nursing students’ clinical competence. Or more to the point, incompetence. If you’ve ever wondered how the care equivalent of Dr Mengele can somehow manage to hop from one disastrous placement to another without sanction, the all too familiar quotes from mentors and lecturers have the sort of chilling resonance that will ring bells for any care professional who has experienced student placements featuring laziness, disinterest, lack of empathy and even personal hostility and threats but have been too ‘nice’, too ‘conscientious’ or in some cases, even too scared to criticise or fail a student. This is indeed an eyebrow raising paper.
But sooner or later we come back to the big picture. As we’ve seen only too graphically at Winterbourne View and Mid-Staffordshire, dysfunctional environments may not be the genesis of dysfunctional staff but can certainly provide an environment where the bad apples can fester and even flourish.
In one NHS Trust I worked for, it was common for poorly performing clinical and/or managerial staff to be shuffled off to a desk, given a laptop and assigned to some ‘special project’ with a Mickey Mouse job title and the licence to carry on irritating and hindering people to their heart’s content, only on a less damaging scale than they achieved as manager of a ward.
On the other hand, the more successful, therapeutic environments I’ve come across over the years do things a little differently. Strong leadership is demonstrated by canny recruitment, proper and functional supervision, and a robust approach to casting aside those who haven’t the competence or attitude to care.
It is of course difficult to simply rid ourselves who aren’t performing to the required standard. For starters, what is the required standard? We can easily identify the member of staff who is consistently late or doesn’t turn up at all, but how do we tribunal-proof the getting shot of that care assistant with the interpersonal skills of a sofa, or has an attitude to superiors leaving managers checking the underside of their cars for bombs?
Please don’t go having nightmares about bad apples or even that dinosaur on the mantelpiece, but make no mistake. They’re out there.
[Guest post by Sharon Levisohn]
Mother came home from hospital on Friday, having been in over Christmas and New Year. She has advanced COPD (emphysema) and had a respiratory virus that resulted in pneumonia.
However, her lengthy stay was not due to her illness – a week of steroids and antibiotics settled that insofar as it could be – but the inability to plan a discharge to meet her ongoing needs. The hospital wanted to send her home with three (local authority funded) home care visits plus daily district nurse calls. The social worker could not authorise the home care package without it “going to panel” and of course there would be no more panel meetings until January 7th. Then the hospital suggested a nursing home placement but, despite full-time oxygen dependency and limited mobility, my mother did not meet the criteria for a funded admission. Next they suggested a short admission to a cottage hospital. That was rejected as they thought, frankly, that the journey would kill her. Plan D was to be discharged home with the support of the (health-funded) Re-enablement Team; however, she was not open to this as her condition was too far progressed for rehabilitation. All this time, Mother was in an acute bed – one of those infamous bed-blockers – on a ward with confirmed Norovirus, while the family and I rode the Waltzer of uncertainty and conflicting updates, always aware that she might just give up the long battle with COPD.
What is the point of this personal anecdote of woe over the festive period? I suppose it is not a unique case; even on the ward there were several other patients unwillingly playing the Cherchez La Femme game of discharge co-ordination. How many patients and families in how many hospitals were going through similar experiences? What vexed me – and as a former nurse I am not criticising the frontline ward staff – was that the hospital did not seem to know what qualifying factors were applied to the various options – one might have assumed that they had confirmed Mother’s eligibility before informing her and the family only to dash their hopes. The other bugbear is the responsibility for funding. Surely, if a risk assessment has shown that a frail elderly terminally ill patient has been assessed as needing input from various agencies in order to be at home with the people and dogs and personal touches she loves, which give her a little quality of life, and if we believe that it is better for the elderly to live at home so far as is possible, surely then the funding needs to be provided? Or shall we simply abandon that principle as practically unviable?
On the Andrew Marr show today Ann Clwyd MP was speaking angrily about the poor care her husband received while at the University Hospital of Wales. She argued that nurses no longer display compassion, and one of the reasons for this was because, “since they made nursing a degree course the wrong kind of people are entering the profession… we do not need a load of snooty-nosed pen pushers”.
A couple of days ago Jo Brand gave a response in the Guardian to Mrs Clwyd’s recent statements on nursing. Her view was that nurses are not any less compassionate than they used to be, but that poor management, spending cuts and privatisation were eating away at standards of care. She too raised the question of nursing degrees, though she describes it as “a complex issue that is difficult to read.” She expressed concern that it might have “closed the door to a wealth of potentially impressive nursing staff whose academic skills were not up to degree level.”
I fully appreciate Mrs Clwyd’s anger and upset at her husband’s (lack of) care. Who wouldn’t be angry? But I don’t think nursing degrees are part of the problem, and I’d like to give some reasons why I think that. I hope this goes without saying, but in doing so I am not attempting in any way to excuse or minimise the failings with regard to her husband. Patients are entitled to dignity and compassion at all times, and if he did not receive it that is clearly unacceptable.
Nursing has been an all-degree profession in Scotland and Wales for some years now, and is in the process of switching over in England. I’ll declare an interest here in that I’m a degree-educated nurse who graduated with first class honours from a well-regarded Russell Group university. It was a tough, challenging course, which stretched me far harder – particularly emotionally and physically – than my previous degree in the humanities.
The first point to make is that the difference between a nursing degree and a diploma really isn’t very much. The length of time is exactly the same (three years) and crucially, the clinical placements are exactly the same. Whether a student is doing a degree or a diploma, they spend half their time in university and the other half out on placement – in hospital wards, outpatient departments, community teams. At the end of the third year, they spend the last three months of the course in a clinical area, taking on all the responsibilities of a staff nurse under the supervision of the qualified staff. At my university, the difference between a degree or a diploma was little more than whether you did a dissertation or an extended essay in the third year.
So, if the clinical placements haven’t changed, what about the suggestion that bringing in degrees has attracted a horde of snooty people who are, to use the media expression, “too clever to care”? Personally, I don’t see that it has. When I was a newly-qualified staff nurse on a ward, I certainly didn’t think that my fancy education meant I was too intelligent to wipe a bum. On the contrary, I felt very strongly that I needed to gain the respect of the nursing assistants I was now leading, and that meant demonstrating that such tasks weren’t beneath me. I really don’t see why having more intelligence would make you less compassionate, or that being clever makes you a bad nurse. On the contrary, when I think of the most outstanding nurses I’ve ever worked with, they’ve all been intelligent people. As for the bad ones, they’ve usually been…well, a bit dense. Nursing requires you to juggle a caseload, calculate medication doses, keep accurate records, liaise with patients, carers and fellow professionals, and think on your feet in rapidly-changing situations. Funnily enough, it helps to have something between your ears.
Then there’s the argument that degree courses are deterring people who would otherwise make good nurses. Again, I’m not convinced. I’m willing to stand corrected on this, but I haven’t heard anyone say, “I was planning to apply for nursing, but now they’re abolishing the diplomas, I’m not going to.” In an era of mass education, university degrees simply aren’t the elite qualifications they used to be perceived as. These days it’s practically a rite of passage school leavers to head off to university, and most people with a reasonable amount of intelligence and self-organisation can pass a degree. Some of the students on my course struggled with the essays, particularly mature students who had been out of education for some years. But crucially, those who kept at it did pass. They might not have got stellar grades, and they might have had to re-submit the odd essay, but they did get through. Once they’d done this, a nursing graduate who scraped a third is just as qualified as one who sailed through with a first. As for those few who flunked completely despite opportunities to resubmit work, they really didn’t come across any great loss to the profession.
Finally, it’s important to remember that many things can affect patient care and dignity besides nurse education. The ratio of nurses to patients. The ratio of qualified nurses to unqualified nursing assistants. Levels of support – is there a ward receptionist to deal with phone calls and queries so the nurses can get on with caring for patients? Equipment issues – for example, is the ward getting enough fresh linen? The calibre and personalities of the senior nurses. Even cultural factors can play a role. Those who gaze wistfully back to regimented wards under the dictatorship of Matron might wish to recall that back then Britain was more, well, regimented. When the NHS was founded it was the era of national service, with the Second World War still fresh in everyone’s memory. The values of nursing at the time were essentially military values. We don’t have that culture in Britain any more.
That said, there is the question of whether enough is being done to weed out bad student nurses and stop them qualifying. It makes a good headline to say it’s because universities only want them to write essays. But as is so often the case with a good headline, the reality is more complicated than that. For people who are interested in this topic, a good read is Kathleen Duffy’s seminal 2003 study on “failing to fail” student nurses. Unlike in the tabloid headlines, her focus wasn’t so much on the universities, but on the mentors; the qualified nurses who teach and supervise students while they’re out on placement.
I’m a mentor myself, and I regard it as one of the most rewarding parts of my job. Every few months I have a student nurse with me for six weeks, so they can develop their knowledge and clinical skills. It’s up to me to support them and also to assess both their skills and their professional attitudes. I’ll not just be looking at their ability to perform a task, but whether they interact well with patients and families, whether they respect confidentiality, actively seek out learning experiences, and so on.
For the most part, the students I’ve had come to me have been excellent. Keen, bright, eager to learn. But there remains the question of what to do with a bad student. Hence why Duffy’s paper was required reading when I did my mentorship training. She identified various reasons why a student might not be performing but still pass a placement, which she placed in four categories.
- Leaving it too late – not identifying and addressing problems until the last week of the placement, perhaps not having a mid-placement meeting as you’re supposed to.
- Personal consequences – an awareness by the mentor that this could result in a student’s career ending before it’s begun, with all the ways that might affect them and their families.
- Facing personal challenges – a lot of nurses simply don’t like failing students because they feel it’s not a “nice” thing to do, particularly in a profession that’s supposed to put a premium on being nice.
- Experience and confidence – mentors not feeling sure of their judgement in these matters, or perhaps being worried about getting a hostile response from the student.
Obviously none of these are valid reasons for passing an under-performing student nurse. Ultimately it’s our responsibility as mentors to flag up problems promptly and address them, for the benefit of the public. The take-home message from Duffy’s research is that if the wrong people are being allowed to qualify as nurses and join our ranks, then it isn’t the university’s fault. It’s our fault.