This article will be circulated in Vital Signs Mag no.4, of which we distribute 1,000 copies within our two local hospitals. Feel free to help us with the print cost.
Sometimes you can see the current moment clearer when you look back into the not so distant past. A friend of ours started working as a nurse in Bristol a quarter of a century ago and, after having worked in a different health job for over a decade, has recently returned to nursing. We have asked him what has changed in the meantime. We are always interested to hear about your experience!
Intro
I started my nurse training back in 1999 and qualified in 2002. I did a diploma, nowadays most people do a degree and have to pay dearly for it. So I started off in care of the elderly, which is what I am doing now again. I did that for three years and then I went to New Zealand to work. That’s an interesting topic in itself, the differences in nursing here and there. I spent three years there, then came back to the UK. On my return I worked on the bank, then in cardiology for a few years and then over a decade in a health educational advisory role. I finally wanted to get back into nursing.
The composition of the workforce
When I first qualified in 2002 they had a massive international recruitment drive, mainly colleagues from India and the Philippines. I was new to nursing and they were new to the UK. At that time there appeared to be enough staff and then it became worse and worse and worse. It got to the point where the only way they could solve it was by recruiting internationally again. When they first went out looking for international nurses, they were able to pick the best and most experienced people with 10 – 15 years of experience. Later more and more international nurses arrive who have just finished their training or had recently qualified. I think the skill mix on the wards probably hasn’t changed that much, the ratio between nurses and nursing assistants and so on. There has also always been a coming and going of agency staff.
That’s interesting! Would also be good to look at the age composition. At least on the wards at Southmead you don’t see many nurses over 40 years of age. Gender-wise, on the other hand, it seems that things haven’t changed that much since the 1980s – it’s still only around 10 to 12% male nurses.
That’s right, most male nurses come from India and Africa, whereas only very few UK-trained male nurses come in, at least in acute health care. Perhaps men can more easily avoid getting into debt for a qualification that then pays only a medium wage?
Working times and conditions
I think they changed from 8 to 12 hour shifts in about 2010. I’ve never liked it. Because I spent so many years doing it the old way. With the 8-hour model there was a lot more scope for educational work in the afternoons. You could catch up with things, with the administrative side of things. It just tires you out. But no one stood up against it, not even the RCN trade union. I don’t know what the evidence is in terms of impact on patient care. It can’t be good, I think that are often mistakes made later in the day.
New Zealand and staffing
I worked in a normal state hospital in New Zealand. The staffing was very different, ratios of 5 to 1 pretty much guaranteed. The nurse in charge would also take patients, unlike here. What I think was good was that they talked about acuity when planning the work – acuity meaning, how sick and how much in need of care individual patients were. When distributing work you would make sure that people had only one Level 5 patient (a very sick patient) amongst their five patients. It would be evenly distributed amongst the nurses. Here in the UK you just get one bay, and all patients there might be very dependent. On the other hand there were less nursing assistants. For 25 patients there would be five nurses and one NA, that means that registered nurses would have to do all the washes.
This can be quite nice for the relationship with the patients, that you don’t just dish out medication or insert IVs! I guess the real stress is to keep the overview – if you have five patients, that’s fine, but if you have eight or nine you might start struggling keeping an eye on everything.
People don’t fully understand that if you go from six to eight patients, your workload increases by 33%. People might think “or it’s just two patients”, but it’s actually a lot more work. That is difficult to absorb.
New nursing roles and team spirit
I think one aspect that has changed is that you have way more specialist nurses nowadays. Now you have a nurse for everything, respiratory, stoma, research, you name it. This might be good for individual patients, but it also means that a lot of the staff just floats in and out of wards with little connection to the team and the work requirements and stress. Sometimes they create more work for you. But there at the same time real positives for the patients. Specialist advice when they need it.
That’s what friends in Germany say about work on the wards in the 90s, that ‘the ward’ considered itself as one team, from nurses to health care assistants to students to house keepers and cleaners – but that the splitting up of work tasks have also split up the team. Nowadays you have phlebotomists or domestics who quickly float in and out, and you have new ‘hierarchies’, such as trainee nursing associates.
Yes, you had this tighter unit where you almost had to do everything. You’ve had to rely on each other a lot. Today, some of the specialist nurses also think that they are a bit special – it creates differences. You have more nurses in black uniforms or ACPs (advanced clinical practitioners), meaning, new hierarchies. Their role means they work more like doctors, rather than the nursing team. You feel that a little bit, but it’s only small things.
Additional work tasks and digitalisation
I think most changes had already happened twenty years ago. We were already taking bloods or cannulating, something that only doctors would do before. Of course, there are changes when it comes to the use of IT. I am still old school. I used to come in, sit down and write down everything from the handover on a piece of paper. Now you have print-outs. But they have to be up-dated, and they are often not updated. Or people are unsure which bits to take out, so you end up with more and more information, which can become excessive and dense.
I think doing observations on an iPad is easy – if you can find one – because it’s just figures. But doing intentional roundings etc. digitally would mean that a lot of small personal bits of information (patient was anxious about seeing a relative; patient didn’t like to drink water without squash) that you might write down for the next shift, you wouldn’t enter into the IPad.
Relation with management and pressure to discharge
Again, often those people who ‘manage’ the patient flow are quite remote from the ward. But a real positive thing over the last years are the efforts to understand where care is best delivered – and efforts to provide more care at home. The ‘Hospital at Home’ teams are now more embedded in the discharge process, which is a good thing. I don’t want to see people in hospital, I’d rather they could be home. The discharge pathways are more discussed now, for example the different levels. Pathway zero means you can just go home, for all the other pathways you have to assess the patient when they are at home – not just when they are in hospital and everything is provided for them. That makes sense, if it is safe for the patient. If it’s safe for them to go home and then someone can go with them and look and help them have a wash and so on – over a couple of weeks, making sure that they’re coping in their own home. It’s just that this requires a lot of staff. We often hear on the ward that the team in the community ‘can only take so many Pathway One’s at the moment’, meaning, they don’t have enough staff to assess the patients with more care needs. So people end up waiting in the hospital.
And I guess over the last twenty years a lot of community and family structures that could also help people at home have been further decimated.
I don’t know what the evidence is on that. One of the great things about nursing is to see that there is love, that there are really strong relationships between people, between couples or siblings and so on. Though there is a close link between poor health and poor relationships.
But back to the question of the pressure to move patients on. On one hand we know that things are busy in ED, that it is not good for patients to be stuck there, and we try to find empty beds – on the other hand you are often overworked to such a degree that you don’t have an interest in moving patients on too quickly. Admitting or discharging patients comes with a lot of administrative work. These pressures can lead to issues moving onto the ward they need.
The pressure to move patients on is high and sometimes people make the wrong decisions under that pressure, patients end up on the wrong wards and so on. There is a target of moving people out of ED within four hours and that clock is ticking. I can go on a computer and I can see that individual patient’s clock ticking. Then there is actually a chart on the ward that tells us our KPIs – our ‘key performance indicators’. I know these exist but because I feel we have little control over the working environment. And sometimes it is better to have time to talk to patients and to ask them how they are feeling, rather than churning them out as quickly as possible.
The increase in administrative tasks also meant that the role of the ward manager has changed a lot in the last ten years. They have become supervisory and May spend less time with patients. Some get involved with the patients sometimes, others not. That also changed the role of the nurse-in-charge, who now coordinates the actual work a lot. There is still a lot of self-organisation, we all have an input when it comes to who works where on a given day.
The self-organisation element is a difficult one. On one hand big management relies on the fact that the work gets done and they know that people work best once things are fairly horizontal and self-organised. On the other hand they always need someone that they can put under pressure, a person who tells them what is happening and who can pass on order from the top to the ward level. With the bureaucratic tasks and the various computer visualisation of the patient flow they want to make a hierarchy look like ‘objective requirements’ – it is a hierarchical decision to keep staffing and number of beds limited to a certain number, but with the computer program and figures you just see the ‘objective fact’ that patients are waiting.
That’s right, you can see the patient flow on the computer system, or things like where medication that is needed to discharge a patient is currently processed, thanks to barcode scanners. It is pretty much in real time. Transport is also digitalised. Then you can see the number of predicted discharges, compared to actual discharges. You can see all the people waiting in ED and how long they are waiting. I can also see where the empty beds are coming up, when people declare them. We can see the pressures and we can understand them, but we don’t have much control over them. Management is all for self-organisation on a daily level, when everything is working smoothly – but once something is going wrong and people make mistakes, then they enter the scene.
Bureaucratic tasks of a nurse-in-charge
Each morning you’ve got to go through every patient and say they have these and these criteria-to-reside. You have to be sick to be in the hospital. If you are a 50 year old male with family support, you might actually want to go home. But what if you are homeless or if you are 80 and alone? We have whole wards full of people who don’t have criteria to reside, but no place to go. So you have to record this information at the beginning of each shift.
Then there are further computerised programs like ‘Safe Care’. There you have to record how sick your patients are and you give them a number, a score. It’s a bit like the acuity thing I was talking about earlier on. You’ve got to add all these up and then the computer will go: “Oh, you are 1.5 hours over your allocation.” – meaning, you have too many staff for this amount of patients with this degree of sickness.
Beyond the hospital
All in all the problem is that we don’t have more beds than we had 20 years ago, but the population is bigger, the aging population is bigger. There were major changes in the NHS structures beyond the hospital. They always invent new names for the various bureaucratic layers, such as the commissioners. They make decisions about how much care people in a certain region can have. They have the capitalist overview, so to speak. I don’t care if the hospital overspends by £1 million, as these figures are arbitrary anyway – but the commissioners do. There used to be five different ambulance trusts in the South West, now there is only one. So there is a process of monopolisation, while at the same time some work is outsourced to small private providers. This is decided over our heads.
The Trade Unions
The unions in the health sector have seemed to have changed so little over the last 20 years. They were invisible then and are still difficult to see today. There has been industrial action and strikes but really they continue to fail to grasp the real problems people face today. The RCN wants to have a new pay scale for nurses. Meanwhile the lowest paid get pay rises to stop the Trust breaking minimum pay laws. Unison couldn’t get their members out on strike due to anti-trade union legislation. If we can look for collective struggles and stick together we can win more than the unions can imagine.
