Nurses of the future learn the key lesson of caring

Being compassionate is as important as being clever, but is dignity high enough on the agenda in teaching nurses? Sheena Hastings reports.

COMPASSION and caring, two big words you’d immediately associate with the role of the health professional. You don’t get in to Sheffield Hallam University to study for a BSc in Nursing unless you have a proven track record in both and B-B-C grades at A-level. Rather than, as some nursing studies courses do, taking students on the strength of their written application only, suitable candidates (there are four applicants for each of the 600 places on the course each year) are assessed in a group task and also interviewed rigorously.

The average entry age is 28, and each new student will already have worked in an allied field, whether in a nursing home, with disabled people, learning-challenged children or as a health care assistant or auxiliary in a hospital. A few have also had intimate experience of caring for a sick or dying relative. Some have hankered to become a nurse for years, but waited until their children were grown to apply for the course.

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Meeting a group of first, second and third years, it’s immediately obvious that there are many skilled communicators here. They’ve come to discuss the findings of the new report of the Commission on Dignity in Care, a wide-ranging study by senior NHS managers, charities and council chiefs aimed at stamping out neglect and abuse in hospitals and the care system.

Among the report’s headlines are that some carers and nurses treat older people with “contempt”, and the elderly are, in some places, suffering humiliation and degrading treatment on a daily basis, while basic respect for human rights is ignored.

Sir Keith Pearson, speaking on behalf of the Commission, said that healthcare workers who do not meet required standards on dignity for elderly patients should lose their job and added: “If we get dignity right for older people we will get it right for everybody...” Too often the elderly are seen as a nuisance, referred to disparagingly as “bed-blockers” and “patronised” by use of language such as “love” and “chuck”, says the report.

As with other nursing courses, 50 per cent of the year is spent by SHU students in clinical work at hospitals across South Yorkshire. Almost every one of the students I meet has already spent at least one block of training “on the job” supervised by a trained nurse with an extra qualification in mentoring undergraduates. They’re passionate about their chosen field, and keen to share their perceptions of the realities of nursing, the factors that can militate against nurses always doing their best, and the so-called dignity agenda – which applies to all areas of nursing and is built into every strand of their course.

There’s a general feeling that qualified nurses sometimes take the rap for failures in care that are not actually theirs. “To a patient it’s not always clear who is a nurse and who is an auxiliary or a health care assistant – and they have a much lower level of training. To a patient, though, it can look as though they’re all trained nurses,” says one young woman.

Her colleague adds: “I worked as a care assistant in a home for the elderly and our training was one dvd about health and safety and how to lift and move people.”

Training of health care assistants, support workers and auxiliaries does seem to vary from one NHS trust to another. Another student had worked as an auxiliary and had received three training sessions, “...and none of it was about how to be nice to people.”

A fair number of students in the room felt that the CDC report’s point about addressing patients with affectionate words such as “love” and “dear” was contentious. “Where I come from everyone calls everyone ‘love’ and nothing patronising or insulting is meant by it, it’s a cultural thing,” said one female student. “Isn’t it more about how a word is said and the staff member’s general attitude, rather than whether it’s used at all?”

One male student (they are 15 per cent of the intake) made the point that very small details can make a huge difference, especially to elderly patients. “Something as simple as passing someone a drink or making sure their food is within reach takes no time at all.”

The young man next to him felt that one of the obstacles to giving the best care to patients was the huge and ever-growing mountain of paperwork facing the trained nursing staff on a ward. “At the extreme end, when I worked in mental health care, risk assessments on top of risk assessments had to be done, and in some cases one patient’s care plan for the week could take up to seven hours.”

Several students mentioned the high level of mentoring they’d received in hospitals, but a couple mentioned having had placements on wards where staffing was poor and morale also low. One said she simply hadn’t felt she could give care with a smile towards the end of a 13-hour shift and thought they should be abolished because they compromise patient care.

A colleague disagreed: “You don’t get a lot of long shifts together, and I think they give you the opportunity to get to know your patients properly.”

There were tutors in the room, but nonetheless students seemed genuinely to think the balance of skills teaching and the business of communication with patients was about right. “We’re taught to think about the dignity aspects of what we do all the time; the approach is holistic. No-one goes into this because they just want to carry out procedures and not care about the mental and psychological effects on the patient of being sick and having treatment,” said one woman. But another added: “There are so many tasks to get through that it can be difficult to find time to talk to patients.”

One woman said: “When I was on a ward and stopped to talk to a patient it was frowned upon and seen as neglecting your work.”

Regarding the often-repeated criticism that nursing was better in the old days before degrees were introduced and that today some nurses are “too bright to care” or “too posh to wash” a patient – no-one agreed. “You need to understand fundamental cell biology, of course you do. Why should a patient have a well-educated physiotherapist and not have a well-educated nurse? It doesn’t mean we don’t care.”

Another student added: “There are a lot of tasks to be done when you’re out there working on a ward, but I wouldn’t want to do this job if I thought that when I’m qualified I wouldn’t have time to get to know my patients and care for them properly.”

Nursing course leaders Barry Aveyard and Jo Stone feel most nurses do a very good job, some of them in very difficult situations with poor staffing and big wards of very sick patients. “There will always be good and bad,” says Jo. She and Barry sign off graduates as fit to practice, and most currently get some sort of a job in the NHS or independent sector within six months.

“Sadly, there are some nurses out there who are failing to do a good job, but I was a patient a while ago and the sister came round every morning and said good morning to every patient. That kind of thing counts when you’re at your most vulnerable, and such details cost nothing.” Barry adds that part of nurse training is spotting and reporting someone else’s poor professional practice. At SHU a few students have had the courage to blow that whistle.

HOW NHS JOB CUTS MAY PUT CARE AT RISK

According to a new report by the Royal College of Nursing, 27,000 NHS jobs have been earmarked to be cut. While there is no set overall safe staffing level on wards, evidence shows that on NHS wards where care is compromised daily due to short staffing, there are twice as many patients per qualified nurse than on wards where care is uncompromised – an average of five versus 10. With the average NHS ward having a ratio of eight patients per qualified nurse, this raises potentially serious questions about how frequently patient safety is put at risk. The report also highlighted skill mix changes on NHS wards over a five-year period. In 2005 the average was 65 per cent qualified nurses to 35 per cent who were not. Between 2005 and 2009 this figure fell and qualified nurses accounted for only 60 per cent of nursing staff. Qualified nurses are only 48 per cent of the staff on older people’s wards.