How will I shape the year of the nurse and midwife?

It’s New Year’s Day and I’ve seen a challenge to take up. Set by @BloggersNurse as we start the Year of the Nurse and Midwife I am planning on trying to write at least once or twice a month in 2020 on the themes suggested. 

January 1st and I’m thinking about how I will shape the year of the nurse (and midwife, please note I mean to be inclusive). 

It’s 41 years since I entered nurse training; my shape and that of nursing and midwifery have altered. Overall, the two professions have fared better shape-wise than me.

I trained to become a State Registered Nurse (SRN) in England, moving into a profession held in high regard. 

There’s been the transition to degree based learning, and recently apprenticeship programs. All routes opening to a career of varied opportunity. 

What shaping influence can I have? The immediate one as a senior and experienced nurse is as an example of being open, kind and flexible. 

I have to be open about how I work, and be prepared to let others lead where they have ideas and strengths that I don’t possess. Be ready to adapt and adopt fresh thinking and take risks to make gains in service improvement.

I want to be kind and even kinder, to all those in my care. This will be patients as well as my team colleagues, and those in the wider care community in which I work and have a social media presence. In particular it’s those who are exploring the possibility of nursing as a career, or already in training, to whom I should be an example. Showing enjoyment and enthusiasm for our work, and giving such people time will help them be great nurses of the future.

I need to be flexible; my career has had twists and turns; some hoped for and some unexpected. This has helped me appreciate the opportunity of being ready to try something new; to allow me to be trusted by people such as team members when they require some wriggle room - flexible working to allow for family issues for example.

Applying this to shaping the year of Nurse and Midwife? 

Being an example, supporting those I come into contact with and reaching out through social media. 

Embracing and getting involved in events to celebrate nursing, and show the value of nursing work to those who question what nursing is.

Supporting those I work with to look at what we do, and see how the work can be done differently. Getting them to speak up, in person, in blogs and engage in further education so they can be shaping too.

Change happens; being prepared to influence the outcome is a way I can contribute to the year of the nurse and midwife in 2020 and beyond.

Feelings of an ad hoc carer and frustrated professional

Just now I'm aware my mum is undergoing a endoscopy and I'm at home after spending a few days with her. In my earlier post about the NHS in November 2017 I laid out my views of what we were experiencing.  
Now it's time for an update and perhaps less positive reading.
After discharge from a 3 week stay in a rehabilitation bed the Friday before Christmas mum was experiencing trouble with reflux from what we eventually discovered (in a post Christmas telephone call with a GP) was a sliding hiatus hernia. This was known about in hospital yet no mention of it was ever made.
Mum has gradually regained her mobility and with support from the family and neighbours was managing just about at home. 
The big problem has been to get anyone to take her painful regurgitation and reflux seriously, along with her weight loss. For a serious cook like mum, who enjoyed a varied diet and particularly going out to eat the reduction in appetite and feelings of hunger have been a depressing downward spiral with no sign of improvement. 
The oral medicines prescribed to improve the situation were having no chance to work.
We've tried all sorts of things; bed head end elevated, mum using the internet to make sure she was using NHS advice for her diet and the variety of medication that was promised to make a difference.
Only this week have we got a GP to call round; the vomiting of almost every fluid and food mum has tried to take was largely ignored because its all 'infection'. Mum has lost half a stone in recent weeks and we believed we were approaching a crisis point that could surely have been anticipated with better community support. The community nurses who visited shortly after discharge told mum they'd keep an eye on her; though hearing impaired mum got the (correct) impression she'd not see them again. 
The senior GP who mum got through to thought she was calling her rehab place; we'd made it clear to the surgery that mum was home...
So between family members and her marvelous neighbours we've tried to find attractive foods and fluids; my catering experience helped here though only marginally.
This week, having been forced to take a frail and low energy mum to the local hospital for a blood test we reached crisis point. The 111 doctor called to say her bloods deranged and needs to go to hospital. So mum is now back in hospital and having her endoscopy. We'd considered getting a private consultation to see if we could get someone to take notice. 
For us, and my experience in the last week this seems unnecessary; felt like trying to keep mum out of hospital (understandable in some way given recent news) though at the expense of ambulance crews and long (overnight) waits in A & E. And we had more than one nurse advocate trying to get help for her. 
Where is the multi professional review and support for older people in the community?
Were mum without family and her support network I dread to think what would have happened. 
It's frustrating and we have some inside knowledge that you would expect to help get us further; it's frightening too.
Right now I have to trust my hospital colleagues and keep faith in the system overall; for Mum and as so many other carers have to do day after day.
As I finishing writing this mum's GP surgery have called me - they're trying to get hold of mum and wondered where she was - her blood results need rechecking... they are surprised (and relieved) she's already in hospital... where's the communication? 

Putting pathways into perspective

Once again I'm exercising the slow blog style; of late the concerns about care pathways have been in the thoughts of many, particularly in end of life care.
The recent report on the Liverpool care of the dying pathway, (LCP)  'More Care: less pathway...' by a group chaired by Baroness Julia Neuberger has led to much soul searching  particularly amongst those who had time to learn how to use the LCP correctly. 

Proper use of the LCP tool (its just one tool - not a whole toolkit) left people at the end of life (who are be believed to be within approximately 72 hours of dying, as far as professional judgement can be accurate) freed from unnecessary treatments and interventions; it enabled all those involved to have an understanding of what was happening, with a mutually agreed approach towards letting the death happen whilst keeping comfort, dignity and respect for the dying person at the forefront of the care that needed to be delivered.
The report speaks of evidence of good practice yet it reaches the conclusion that the LCP should be left behind as, in the name of the LCP, much poor care of the dying had taken place. I believe it likely that the poor care would have taken place anyway as there would have to be a culture of accepting poor care, to allow misuse of a tool such as the LCP.

Healthcare professionals do need to be careful about terms such as care pathway; it is all too easy to take a professional short cut when faced with pressures of work. In the last week research undertaken by Dr Kristian Pollock  highlights the effects busy-ness for care staff has on their ability to interact with the dying person on hospital wards.
So this got me thinking about pathways; whilst taking a train journey a few days ago I listed pathways I could think of:

• Stepping stones
• Gravel
• Wooden deck
• Grass
• Slabs
• Bricks
• Mud
• Tarmac

We have nearly all these in our garden; some very short, not easy or pleasant  to use; others take us on a longer route past lavender and herbs; have better views, and are much easier on the feet. So what's my point?

We should carefully consider facilitating choices for the dying person, beginning with a personalised approach to planning for their end of life. A care pathway that does not allow for deviation from the route is limiting. It's a bit like going round a stately home following the arrows  under the beady eyes of the custodians. Had healthcare workers fallen into that way of thinking with the LCP? Only one way to travel, no matter how welcome or not you may be; ignoring vital information and potential options for alternatives because the 'pathway' is well fixed.

Lets get out the maps, and look at the routes we can travel with the dying person toward their death. We will need to be flexible; prepared to risk going "off piste"; getting dirty and even lost. The important thing will be not to leave those who are dying thinking they are alone. 

Be creative and passionate about what you are doing; take them into your relationship with the dying person while they explore the pathway(s) to take.

A terrible thing to have to write...

In the last 24 hours a couple of  social media interactions have linked together to cause me to write. One is ongoing and concerns the care of a dying person; having worked in Hospice and palliative care  for a couple of decades I can claim to know something about this. Added to this is my experience of end of life care that started on my first ward as a student nurse, that was even longer ago.    Follow @nursemaiden on Twitter to see the story unfold, in real time.
The other link was made this morning as I read @RoyLilley and his blog piece of today, see It's all going horribly wrong

As a service provider I am dealing with several commissioners, except there don't seem to be any out there. There are well intentioned folk in positions that have no decision making power; there is no-one in place in their organisation who can negotiate or decide what to do about the current financial year let alone the next one. In the meantime services go on being poor inequitable and not joined up. Commissioning is getting a bad name through this; as Roy Lilley points out the layers of interference and in my view obfuscation are causing serious problems;  in particular I find in creating change on the ground. 

We are not seeing a new dawn of person focused services - despite the efforts of providers to work that way; we are seeing a shuffle of the layers of control - a shuffle in inexpert hands that will be a whole lot messier than 52 card pick up. It is leading to a dying of the light in which the rules and regulations over reporting and numbers will lead decisions on the provision of care. I'm not convinced that concerns about the money (spending or saving) are behind the decisions; only being in a place where having control counts.

All around us though the dying, frail and vulnerable of all ages are only being supported by dedicated on the ground staffs day by day. Often they are kept from doing the right thing by the 'rulers' or vacuum and this is leading to provision of poor, less than best services and no sign that things will improve soon. That is a terrible thing thing to have to write in 2012.

Time to Care, Dignity and Nutrition - a mixed result for nursing and management

This morning in the UK we awoke to the news announcing the publication of the CQC report Dignity and Nutrition inspection programme, see it at http://www.cqc.org.uk/_db/_documents/20111007_Dignity_and_nutrition_inspection_report_FINAL.pdf


The media focused on the poor practice and dubious standards the inspection team found, see  http://www.bbc.co.uk/news/health-15279796. The inspection teams were formed including CQC Inspectors, practising nurses and 'experts by experience' such as members of Age UK. I like that approach, the latter parts of the report explain how beneficial it was to the process and getting a relatively open response in areas under inspection. My own experience in the first Cancer services review conducted by the the original generation of the CQC line, the Commission for Healthcare Improvement (CHI) used nurses and Audit Commission staff. We didn't use patients to conduct interviews though there was work done with seeking their views. We are at last engaging those who are cared for in the process of inspection and evaluation of services. 
There were good practices in place though the consistency varied; it must be acknowledged too that some poorly resourced areas managed to meet the standards whilst others with more resources did not meet them. The report draws attention to the suggestion that mangers are not consistently addressing issues of poor performance (p13).


Alongside this are variations in the application of practice where some managers did not seem to have an accurate knowledge of what was happening, “When we asked about the red tray system there was a mixed response. Some senior nursing staff told us that the red tray system was in use but the junior nursing staff on the ward did not know what the red tray system was. They told us that they had never used it.” (p15).


Another quote was  “All the ward staff we spoke to on the stroke unit said they felt the unit was understaffed and the current levels were not appropriate to meet the needs of the patients.” (p13). 
What concerns me about these three examples is the theme of management competence. Inconsistency of performance should not be a problem if the managers understand how to address the issues and are supported in doing so. It is time to reclaim best practice - and encourage fellow nurses to speak up when poor performance is seen so it can be dealt with promptly.
Management by walkabout has been talked about in the past; it is one way to observe what goes on in your area of responsibility. It makes one visible to the staff, so they can speak to you as well as the people in your care. That would help improve reduce the dissonance between the presumption that those one manages are doing the right thing, and positively making sure they are doing the right thing. You stop looking quite so foolish as a manager that way. And the final quote about "all the staff we spoke to... " - there were presumably more than two (though this should apply even if only one) left me wondering about the support managers gave to staff to raise concerns and take them seriously. And why were the staff letting this go on without taking it further?
Somewhere managers have to be able to strike the balance that encompasses in the phrase 'the people in our care' not only the people who we are striving to help as nurses, but those in our employ for whom we also have a duty of care. Then we might have a better chance to get things right.

What a week for healthcare

Whilst we wait with bated breath to see what happens about Southern Cross and all their care homes, we have had the traumatic scenes of the treatment meted out to the clients of Winterbourne View Hospital for People with Learning Difficulties, near Bristol, and today we're told the CQC have tipped off the police about the Pilgrim Hospital in Boston, Lincolnshire.

What a week; in the meantime I have been working along with 30 colleagues on looking at ways we can further develop the quality of care we deliver using personalisation as a starting place.
I guess we're lucky to be employed by an independent sector charity who want to develop and encourage the staff to do the same. It doesn't always feel like the whole charity are behind us but for those tasked with delivering the care ot our clients that kind of atmosphere is necessary to maximise the benefits to the patients and staff and reduce the risks of something going wrong.

Southern Cross is a classic case of market forces doing their natural thing; it remains to be seen how this will pan out.
Whilst details around the Pilgrim Hospital are lacking it must be serious to warrant police involvement. Whether it is one person or a system that is at fault we'll have to see.
Winterbourne View is in a league of its own; in terms of management failure; cultural failings in terms of acceptable care as well as an apparent lack of diligence by the CQC in the area.
When will people in positions of responsibility for quality and ensuring the safety of the vulnerable in our care take up even the slightest hint of wrongdoing and investigate thoroughly.
The principle of the CQC is OK; it remains to see if it was a local failling or so big a failure to warrant changes ot the way it is run.
My own experiences do not bode well for it's reputation as efficient and speedy to respond in setting up new managers, vetting and the other tasks necessary to monitor the quality of healthcare. Mainly because it does not seem to have sufficient numbers of inspectors to do the unannounced visits we should all be ready for and wary of, lest failings are exposed.
It's like driving - the more police officers about in marked vehicles on the road - the better we all are.
Let us not forget the duty of care we owe to those who use our services; that quality is worth investing in and let us see a thorough investigation into what has occurred with proper penalties imposed on those who are accountable for what has occurred.

The NHS and competition - top people speak up

In today's Times newspaper Public sector section (no link - payment issues) Dr David Bennett the new chair of Monitor outlines his thoughts for the future of competition in the NHS. If you're wondering, Monitor is the economic regulator for the NHS see http://www.monitor-nhsft.gov.uk/.
In addition the BBC reports comments from Sir David Nicholson NHS chief, (note to self - what is it with David's and top jobs just now?) see http://www.bbc.co.uk/news/health-12566716.
Dr Bennett makes a number of points. He begins with the 'inertia' of the market caused by what is in essence the buyer's (GP's) inexperience as buyers - so they will need support (empowering in his language). To me that means experts and experts mean money; so there is a cost to empowerment. Competition may not thought be universal in the NHS - Dr Bennett reportedly says it will exist 'where appropriate'; what does that mean? In specialist areas competition will be slower coming but I sense no discomfort in Dr Bennett at all areas eventually having some element of competition. What that would mean for hospices?  We'll have to have clear business models to use when negotiating; a clear model and measure of quality making explicit the benefit of our style of service. We'll need to be 'robust, rigorous and transparent' he says.
Another important point he raises is a belief that competition based on quality will transform the health care sector. He thinks individuals will look something 'varied [where] an individual can find something that better suits them'. This helps me understand the need for personalisation in our services and well as give a push to the need for explicit quality markers.
Meanwhile Sir David Nicholson has issued a warning that some hospitals may find the future difficult; the landscape of management of hospitals is already changing with Circle coming to run Hinchinbrooke later this year. Competition rules; those who will survive in 10 years time will have become adept at changing and maybe more efficient but there will scars and casualties along the way. How ready are we for this?

Loving your architect - not letting the bully kick down your sandcastle.

It has been reported that Mr Gove (Secretary of State for Education, in the UK) has been architect bashing, again. Last weekend he told a Free school conference that there would be no fancy architects involved in free schools. Indeed he rubbished the profession altogether he said “We won’t be getting Richard Rogers to design your school, we won’t be getting any ‘Award winning architects’ to design it, because no-one in this room is here to make architects richer.”
(Details at: http://www.bdonline.co.uk/news/michael-gove-in-new-attack-on-award-winning-architects/5012674.article#ixzz1Cw0a7GIn
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Why should we worry in healthcare? I have been engaging with the architect appointed recently to help us consider our new hospice building. He has won an award or two - but even if he had not done so I would still value what he brings to our discussion and ideas. The ideas of our team are given respect and considered. We get to discuss what care means; how we will deliver it and ways in which we can change our practice for the better.

The building will contribute to the future of palliative and end of life care; it will facilitate the delivery of our small revolution; the environment in which we will work will be vital to get right. Our architect has real skill in taking our words and making them come alive in drawings. It is a creative process I treasure; it will bring a result of richness and utility, a place to celebrate life and quietly care when life is ending.  Last month the BMA published a report about the psychological and social needs of patients and the importance of healthy designs. See: http://www.bma.org.uk/health_promotion_ethics/psychologicalandsocialneedsofpatients.jsp 

In this report architecture has an obviously important role to play. There is clear evidence of the importance that an appropriate environment will make significance for the person who is unwell.
I am sure there must be evidence that thoughtfully designed education environments will make a difference for those who have to work and learn in such places. It is evidently so for those in healthcare. It cannot be acceptable that buildings such as schools and hospitals that have a high impact on people's lives should be pieces of design influenced by an ideology based on prejudice and a real lack of respect for the talents, training and professionalism of those involved day by day in the provision of new buildings.
We are much more aware these days of railway stations and airports for example that work and those that don't; on that theme the ruination of Stanstead Airport concourse is a classic example of market forces taking control. Architecture can make a difference; there are lots of media examples that demonstrate the public appetite for design and good buildings.

So I believe we should love and support our architects; it is an often under appreciated profession that we belittle at our peril. The peril is particularly for those who are vulnerable; children and those who are sick. Let not the hooligan kick down your edifice because they don't like what you've built; the risk is that this is letting the bully win.