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	TX: 10.07.07 - Call You and Yours - Nurses PRESENTER: LIZ BARCLAY AND WINIFRED ROBINSON
	THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT. BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE 大象传媒 CANNOT VOUCH FOR ITS COMPLETE ACCURACY. BARCLAY Hello and welcome. Today we're devoting the whole of the programme to nursing. There are 400,000 qualified nurses in the NHS and your experiences good and bad when you come into contact with them account for a large number of the e-mails, calls and letters to this programme. We reported recently that complaints against nurses are growing and you contacted us with your accounts. So today we'd like to hear from you again. ROBINSON We expect that nurses will care for us and for our relatives but what exactly does nursing care mean in the increasingly technical world of modern medicine? Some of you think that the way we train nurses - moved off the wards and into the lecture halls - and that as a result we're turning out nurses who lack the basic temperament and skills to do the job we want. One professor of nursing we spoke to believes that qualified nurses have allowed the core of their work - caring for patients - to be passed to unqualified assistants, so that nurses have swapped their most important job of caring for the jobs the doctors didn't want. Do you let us know what you think. BARCLAY The lines are open so ring us now on 08700 100 444, you can e-mail via the website or text your comment and the word You to 63399. Calls should cost no more than 32 pence, texts between 12 and 15 pence. Now with us throughout the programme to respond to the points you make is Claire Rayner, a trained nurse, writer, campaigner and president of the Patients Association. And a little later we'll also be joined by Howard Catton, head of policy at the nurses professional body The Royal College of Nursing. ROBINSON Claire Rayner you trained as a nurse and recently you've spent long spells in hospital, what was your experience of the nurses as a patient? RAYNER Currently compared to what it was, when I was young. I don't want first of all to sound like a dreary old bat saying of course it was better when I was training. I'm not doing that. I'm not being an elderly person saying the young ones are useless. Much of what they do is remarkable and important and at their best they're superb still. Can I make that clear? And I admire that. But as someone has already told you they've forgotten the core, they're very good at the technical things, they saved my life in intensive care. But the care thing has vanished. Example: I had moved on to a high dependency ward, a nurse is supposed to be with you at all times but it didn't happen that way and I began to feel sick, it was a common problem, I was on my own. And I rang my bell and I rang my bell and I rang my bell until eventually I had my thumb on it all the time and I was sitting like this, it was pretty obvious what was wrong ... ROBINSON With your hand over your mouth. RAYNER ... and eventually before I'd ruined the bed and - oh it would have been horrible - a nurse did put her head round the door and I was pointing at the bathroom and thank heavens at least she knew what the signals meant and she went into the bathroom, came out with a look of utter horror and disgust on her face and sort of threw it up - your bowl - it landed on the bed and ran away. ROBINSON Now if that nurse had been caring for you as she should what would you have wanted her to do? RAYNER I would have wanted her to come immediately with the bowl, put under my chin where it needed to be, put her arm round my back and hold my forehead because when they do that, anyone does that, you don't have so much discomfort, it keeps you steady. So if you're throwing up you don't keep throwing yourself forward which is the instinctive thing to do, actually help to hold me and stop that from happening. Actually would mop my face because you always sweat dreadfully and she would have cleaned me up and wouldn't have left me until necessary. ROBINSON Well Claire Rayner thank you for that for the moment and we'll come back to you a little later on. Liz. BARCLAY Well the enduring image of nurses as angels probably dates back to Florence Nightingale, her lamp and the Crimea War. But the Royal College of Nursing's archivist, Susan McGann, told me that even in Nightingale's day nursing care wasn't above criticism. MCGANN There have always been complaints about nurses, that's probably inevitable. The image of the nurse is such an iconic figure in our society, you know that young girl, pristine uniform, always smiling, always dutiful. So perhaps when many patients meet up with somebody who doesn't quite match up to this wonderful image they feel they've been hard done by. BARCLAY Well we've already had a number of e-mails calling for the return of matrons, was there really a golden age when the matron ruled the wards? MCGANN No I don't think there was. If she ever did exist it must have been at the end of the 19th Century when the hospitals were independent and the matron would be an upper middle class lady who had complete control of that hospital. But it was a much more simple society and much more simplistic hospital and medicine. Sometimes people think after the NHS first came in in the 1950s this was the golden age of the matrons but if you look at history or the evidence matrons actually lost status and power when the NHS came in. When the government was putting in place the management structure for the NHS the nurses, nursing profession, was ignored completely. They were so intent on wooing the doctors, to get them to comply or come in, that nursing was hardly mentioned. And the main structure of management was the hospital management committee and nurses weren't given a place on those management committees. BARCLAY So where have we got this myth in our heads then? MCGANN It's a good question, I mean to some extent it must start with Florence Nightingale, that image of Nightingale with her lamp looking after everybody, you know the mother figure who knows all the answers, will protect us all, I think that's really deeply embedded in our culture. But I think the media are a lot to blame as well, they love this image and they love the image of the nurse, I think nurses sell newspapers for some reason. And if you look back over the newspapers you see every five years there's a headline which says: Nurses drop the Nightingale lamp - or something to that effect. BARCLAY So on the one hand they stand it up, on the other hand they knock it down? MCGANN Yeah exactly. Since the second half of the 19th Century, NHS 1950s, hospitals have become much more transient, everything - the developments are happening so much faster within medicine, within drugs, the nursing has to keep up with these. Patients are in hospital much shorter periods, the turnover's quicker, there just isn't the same sense of continuity where you could have this one person who knew everything that was going on in every part of the hospital in all the different areas. That's just not possible in sophisticated medicine in hospitals. BARCLAY Who is the average nurse today then? MCGANN I don't think you can have an average nurse in a workforce that big - 680,000 - and the nurses - the role of the nurse stretches from at one end you have these very powerful managers running trusts or you have a very specialised nurse working with intensive care equipment - drugs, procedures - and then at the other end of the scale you have basic nursing whether it's in the community or in the hospital. So it's very hard to talk about an average nurse. BARCLAY Another subject that always comes up in any discussion about nursing is the agency nurse, what's the history of that? MCGANN Well once - back again to the 19th Century, the second half of the 19th Century, when the hospitals all began to set up nurse training schools because it helped to staff the wards, they also realised the middle classes didn't use hospitals in those days, nor did the upper class, so there was a big market for private nurses and all the large hospitals would set up a nursing institution or agency which would provide nurses to go out and nurse in the homes of the middle classes. So the idea of agency nursing has always been there, there's always been a private sector. BARCLAY Susan McGann, archivist at the Royal College of Nursing. And that 680,000 figure for the number of nurses that Susan quoted includes midwives, registered nurses who aren't currently working and those employed in the private sector. Which is why you'll hear a different figure in this compilation of a few basic facts about the nursing profession. BASIC FACTS ABOUT NURSING Between 1997 and 2004 the NHS nursing workforce in England had grown by 23%. Growth has been lower in Scotland, Wales and Northern Ireland. England still has fewer nurses per head of population though, in 2004 Scotland had 7.6 nurses per thousand people, compared with England's 5.9 nurses per thousand people. The growth in nursing numbers has not been across the board, there was no increase in health visitors or midwives and the number of district nurses has also fallen. There are approximately 400,000 full time equivalent nursing posts in the NHS throughout the UK and around 20,000 new entrants to the profession every year. We rely heavily on nurses from overseas, for example last year eight and half thousand of the 31,000 newly registered nurses came from outside of the UK, according to the Nursing and Midwifery Council. Use of agency nurses has grown. A report from the Royal College of Nursing found that in 2004 1 in 10 nurses and midwives working in the NHS was employed by an agency. To train for a nursing diploma applicants must pass at least five GCSEs, including English and science. To study for a degree they need two A Levels as well. All new nurses in Scotland must have degrees. Wales is moving to a similar system. In England a nurse can opt to take a diploma or a degree. The vast majority - 96% - choose diplomas because diploma students can claim grant funding. A newly qualified NHS nurse can expect to earn around £19,100 with an average pay for nurses at around £29,000. The government has said recently it would like to see average nursing earnings rise to £32,000. ROBINSON We've already had lots of e-mails and texts responding to what Claire Rayner had to say at the start of the programme about a lack of caring on the part of some nurses. This from Phil Holsworth who says he's 58: Nursing and medical care for myself has so far been exceptional at my local hospital in Newry County Down in Northern Ireland and also at the local GP. This though from another texter: As a qualified nurse we do hand holding and caring, not as much as we'd like but as much as possible. It's a problem of short staffing and no extra help. So what do other nurses say about the biggest challenges that they face? Well you might think that the views of nurses about their work would be easy enough to obtain but a series of NHS trusts last week refused us permission to speak to their workers. Eventually though Anna Bailey got to talk to some nurses at St. Mary's NHS Trust in London. NURSE I think the main challenges for nursing today are a lot of targets, there's a lot of government targets and we're very much being influenced by them now rather than the patients. We're forcing patients through quicker than maybe we should sometimes and that's to meet targets. BAILEY So how difficult is it to build a relationship with your patients? NURSE I think it's really difficult to build a quality relationship with your patients. The turnover staff - it's a new nurse everyday and it's a new group of patients. We're so busy rushing, everything becomes less priority. Things like helping them to eat, have a wash, taking them to the bathroom - the fundamental basic care needs automatically go to the bottom of your list when actually that should be the first priority - basic care of a person. BAILEY And are you aware that complaints against nurses is up by 20% and if so why do you think that is? NURSE I didn't realise it was quite so high but it doesn't surprise me. People have an idea as to what they should get and they don't always get that. But again we make everything a lot more focused now and in the public eye, so we encourage people to complain because unless they complain nothing's going to change that practice. NURSE The problem these days is lack of morale, it's taken a nosedive over the last few years and I think now the girls feel that no one gives a damn about them. You know we're just numbers. When I trained matron would have known the lowliest student nurse. Everyone knew you and you felt someone cared, you know, now no. BAILEY Do you think that impacts on the work? NURSE Yeah, people don't work as cheerfully, often don't work as a team. I think individual people often feel undervalued and they get dispirited if they're not really quite confident in themselves as people before they started nursing. NURSE I think the main challenges for nurses today is lack of colleagues working with them on the ward. We do have certain wards that have got health nurses assistants but you do have wards that do not have that and if you're short of staff that makes nursing care quite difficult sometimes. BAILEY And whose job is it to provide basic bedside care? NURSE For me the reason why I got into nursing was just to look after patients, for them to get well and to go home and when you look in nursing now that is sort of - that is still the nurse's responsibility to give basic nursing care, if you have an 85-year-old that comes in who can't manage her own hygiene we have to be as a nurse to help her in the morning, to give her a wash to make her look good before her family comes in. You just go - come in, in the morning, give your medication, the next thing you do you look after a patient, this person will call you - I need this - and you go off and do that and by the time you realise it's 12 o'clock. The family are there, they're like oh my mother has not been washed. And like I'm really sorry but I will get round to it. BAILEY How does that make you feel? NURSE It makes you very tired and frustrated that oh why did I get into nursing in the first place. But sometimes you just grit your teeth and just get on with it and [indistinct words] for the patient. BARCLAY Three nurses at St. Mary's NHS Trust in London. That's what they think, so what do you think? Let's go to your calls. Claire Rayner is still here to pick on the points and comments you make and we're joined by Howard Catton, who is head of policy at the Royal College of Nursing. The first caller is John Powell from Manchester, John what's your experience? POWELL Very much split. My nephew was quite young, had Hodgkin's Lymphoma, which is a form of cancer, a few years ago and his treatment was absolutely superb, the nurses were brilliant, they couldn't have done enough for him and he was cured of his illness, which was great. My mum was in hospital a few years ago but because she's quite an elderly lady and not quite sure what was going on her treatment was nothing short of horrendous. BARCLAY Do you put that down to the fact that she was elderly? POWELL Yes. Probably they thought they could get away with more than anything else because she wasn't - she was losing it a little bit, she was quite an old lady, she'd had a stroke. You go into visit the hospital, I went everyday for eight months, and you pass a piece of rubbish in the ward and when you come out an hour later the piece of rubbish is still there. I found blood and stains on a pillow, which you don't expect in a hospital really, when they go on about cleanliness, but if you get stains on the pillow it's not surprising how problems with all these various super bugs because the place just wasn't clean. BARCLAY John, were your nephew and your mother in two different hospitals? POWELL Yes my mum was in North Manchester, my nephew was in Oldham. In Oldham it was fantastic, in North Manchester my mum lost 60% of her bodyweight in hospital and they fed her when she shouldn't have been fed, they didn't feed her when she should have been fed and we made numerous complaints to the heads of the nursing at the hospital and we had meetings with them - my sister and myself - but it was a waste of time. BARCLAY Did you get no apology? POWELL Oh we got - yeah we got a lot of apologies and very long letters saying how sorry they were and how things should have been better because we picked them up on things where they'd gone wrong. But it didn't change things. BARCLAY John, thank you very much for that call. Claire Rayner two points there I think: What about the point that John feels that because his mother was elderly she didn't get such good care? RAYNER I'm afraid our helpline at the Patients Association, we get many calls about older people and what happens to them. Their voices aren't as loud, they're not as willing to bother people. I mean my generation - I'm one of them - were brought up not to make a nuisance of ourselves. So you think two or three times before you ring a bell or try and attract a nurse's attention. That's one of the reasons. And I have to say the other one is utterly basic. An attractive young man with an interesting condition is going to get super nursing care because people find him interesting and worth talking to, they find it's different, you can't blame them, whereas older people don't have the same allure, if you like, they haven't got that [indistinct word] thing. More importantly is the hospital, the atmosphere of the hospital, the morale of the individual hospitals makes an enormous difference. Those little bits about age and attractiveness are down at the bottom. But if the hospital hasn't got a morale well that's - you heard from the nurse from St. Mary's - nothing really works. BARCLAY Howard Catton, what's your response to a situation like that where people are feeling that because their relatives are elderly they're not getting the degree of care - nursing care - that they feel they should be entitled to? CATTON I think we've talked a long time about Cinderella services, it's elderly people, it can be mental health, it can be learning disabilities. Claire's quite right, they're not seen as the sexier services in terms of funding, in terms of perhaps the specialisation, perhaps the media as well. But the critical issue about - particularly about care for the elderly, if you look at the demographics of the population, if you look at our ambition to move more care closer to home, those are going to be an absolutely crucial part of people who we care for, patient groups, that we need to focus much, much more attention on. BARCLAY But if nurses are going to care in the home they are really going to have to take the care part of healthcare very, very seriously and that's what we're saying is missing. CATTON Absolutely and I think one of the key challenges is around finding the time to care. Time and time again we hear from nurses who we speak to that they go into the profession because they want to care, that always has been the primary motivator and it will stay the primary motivator. But if the system - the numbers of - the lack of staff, lack of resources, just the sheer pressure of work always seems to act against that. BARCLAY Let me bring in Elva Knott who's on the line from Blackpool. Elva, what's your experience? KNOTT Well I'm rather concerned about the use of incontinence pads on people that aren't really incontinent, just because the nurses either can't get to them in time or can't be bothered or they have some mobility difficulties and there's no time to take them to the toilet. I find it extremely distressing, particularly for elderly people, just to be told to go where they are and also for the relatives that are watching them. BARCLAY So do you feel then that this is just one symptom of the fact that nurses are not caring as we would expect them to? KNOTT Certainly I do, I think the whole ethos of the hospital, I agree entirely with all Claire Rayner's comments, that actually nursing has just gone out of the window. BARCLAY Let me bring in our next caller who is on line three. Phyllis Holroyd, Phyllis from Fareham, what's your experience? HOLROYD Well I just think they're so understaffed these nurses. Our experience was that my husband arrived on a haematology ward on a Sunday, these were all separate little rooms, and there were two nurses on duty, one of whom had come in on her day off because she didn't like the other one to have to cope on her own. They were wonderful, they were working their socks off but they hadn't a chance. Let down by the system. BARCLAY But in the main you feel that the nurses themselves are as committed as ever? HOLROYD Absolutely, they were working so hard, they left me breathless. BARCLAY Ted - Ted Gee is on the line from Lancashire. Ted, what was your experience? GEE Nothing but good. Last year I had a detached retina followed up this year by a cataract operation and the staff at Blackpool Victoria could not have been better. Sometimes when you're waiting for an appointment to see the specialist you have to have drops in and so the comment that I'm going to make relates to not being able to see what went on but to hear what went on. And I was sitting in a corridor and a couple came past and one of whom was clearly a nurse and she said to the lady: "Take a seat there please, the door next to you is where you will be going in, in about five minutes time a nurse by the name of Pauline will come out, and she's a lovely lady, and she will look after you." On another occasion I heard a nurse say: "You go along to the end of this corridor, turn right, then left and then you'll see the department up there, don't worry I'm going up that way, it's not far out of my way, I'll take you." Now you can't ask for much more than that can you? BARCLAY You certainly can't Claire Rayner, I mean that is very, very positive - explaining and listening. RAYNER Exactly what nurses in an eye department should do. It does occur to me possible that she'd had a specialist training to work - some specialist training - to work in an eye department or an eye hospital. I mean I had to have cataracts done, it was after being in intensive care, it's not an uncommon thing but I had the same sort of experience, they were marvellous at Moorfields. But everyone there had a feeling that they'd all had to do something for the patient, that's what mattered. BARCLAY Zoe Williams is on the line from Huddersfield. Zoe. WILLIAMS Oh hello. BARCLAY Hello, what was your experience? WILLIAMS My mother-in-law was in hospital for five months recently and we just found it appalling really, the lack of basic care, of making sure that she was fed and that she had a drink, not everyday but certainly when she was at her most vulnerable and she really needed somebody to make sure she was eating and drinking... BARCLAY What do you put that down to because you say not everyday? WILLIAMS Well basically I think that the trained staff in hospitals now don't actually see it as a priority to make sure that people eat and drink and if they don't eat and drink, doesn't what medication you give them, they are not going to get better. And I just find it appalling that that's left to untrained staff and nobody is actually supervising them and saying can you make sure that Mrs Willows has had her lunch, how much is eaten and she did lose an awful lot of weight, even though we were making attempts to take food in for her. BARCLAY Howard Catton, the picture we're getting here is not just a patchy performance across different hospitals but patchy in different wards, depending on which staff are on. CATTON Listen I think the issue about core skills, about food and nutrition, they are absolutely essential, they are absolutely critical. When we talk about the pressures that staff are under I know it can sometimes sound as though that's a bit of a cop out, or a bit of an excuse, but I just want to share with you how it links up to the issue around core care. We know that hospitals across the UK are running at bed occupancy rates in the region of 95% and it has been like that for a long, long time. All the experts will tell you it should be 85%. What that means is you just don't have the time between patients to do basic things about cleaning, it puts pressure on time for explanation, puts pressure on time to have a relationship and it is that relationship with a healthcare professional which comes through time and time again as being critical to the patient's experience of quality care or not. BARCLAY And will come back to where we see the solutions might lie but let me get one more call in before Martha tell us about the World at One. Paul is on the line from London, Paul what's your experience? PAUL Well I've got three different parts to the story. My own, which is diabetes on a low scale and a couple of recent small procedures at the local hospital, Central Middlesex, in which the nursing care couldn't have been better if you tried. My father's experience at the Royal Free, my late father who died after five months of being at the Royal Free, where because he was in a geriatric context we found as a family that the only way that we could get consistent nursing care was if we were part of the care process ourselves. And then my wife's experience last year, also at the Royal Free, being treated for breast cancer and that last experience is the one that stands out the most as blindlingly brilliant. We've been trying for the last few months to get a particular nurse in the chemotherapy department at Royal Free a national award, we're not doing great jobs on that at the moment I'm afraid, so Ivy deserves all the plaudits we could possibly give her ... BARCLAY Well at least Paul you've managed to mention Ivy very positively on the radio and we will be coming back to many more of your calls, so please do keep those calls coming in 08700 100 444. ROBINSON The time now is half past 12, you're listening to Call You and Yours on Radio 4 where we're discussing the state of nursing in the NHS. If you want to take part in the discussion you can text us by texting YOU on 63399 or you can call 08700 100 444. In a moment we're going to be talking about claims that the training of nurses places insufficient emphasis on their caring role. So that's what we'll be discussing next after Martha's told us about today's World at One. DONKIN My name's Andy Scott Donkin, I'm a third year student nurse, going to qualify in five weeks. I'm a mature student. I started nursing when I was 27, which is very similar to a lot students around the UK. WILLIAMS You're doing a diploma and why would you have chosen a diploma over a degree? DONKIN At the moment the diplomas are fully funded, we have a bursary for three years, if you choose to study the degree, certainly in my university, you lose part of your funding in the third year. And I have a home, I have a child, I have a wife and I can't afford to lose that funding for those six to eight months. WILLIAMS Now there has been criticism about the course that it's too academic, what do you feel, have the last three years been too academic? DONKIN With the European directive to have 50/50 split for nursing and theory I'd say not. I know we have to achieve 2,300 hours of theory time and 2,300 hours of practical time within the three years. So I've had a lot of hands on experience. WILLIAMS Can you give me an idea of what sort of time you would have committed to basic patient care? DONKIN In the first six months we'll have an essential care or placement, in my case was in a rehabilitation ward and I learnt how to wash patients, I learnt how to make sure they're getting real good nutritional standards, personal hygiene, learning how to make a bed. And at the same time I was going back into college and learning the theory behind why I'm doing it. WILLIAMS Would you have had a supervisor during that time? DONKIN Within placements we have a designated mentor, so we have somebody who's overseeing our practice and making sure we're achieving the standard we should be achieving, they're there to answer questions, to be a sounding board if you like. WILLIAMS Jo Robertson, you're a student advisor for the Royal College of Nursing, what's your take on training, these criticisms that it's too academic? ROBERTSON It's not too academic, students do 50% academia and 50% practice and they do need to know the theory of why they're doing what they're doing, it's not good enough any longer for nurses just to say well we've always done it this way, we have to have some reasons for how and why we look after patients in the way that we do. It is very practical, they are clinically based, in fact there are some changes in some courses significantly over many years. So I believe our students come out as prepared as they can be. WILLIAMS How does this structure, that you're describing, compare with the old style apprenticeships that nurses would go through? ROBERTSON Well in the old days, if you like, and that's when I trained nurses were actually employed by the health service and were part of the workforce. Now the Royal College of Nursing campaigned long and hard to get that removed because student nurses were seen as part of the ward staff and therefore when the pressure was on, when staffing was short, student nurses were just left to do whatever had to be done. We feel the students deserve more than that and what they now get is the full learning experience, they're in university for their theory, and they then go into the workplace as supernumerary, they're in addition to the ward staff. So the ward should be fully staffed and students are in addition to that. WILLIAMS There's been a lot of discussion, lot of criticism, about patient care, do you think it comes down to the way nurses are actually studying during their diploma or degree course or is it about what happens when they actually get into the hospitals? ROBERTSON Well I think our students come out at the end of their courses adequately trained to look after patients. They've had a lot of theory, they've had a lot of practice and they're ready to look after patients but like any other job a lot of it is learnt once you actually start in the post, you can't run a ward unsupervised as a student because you're not allowed to, you have to be supervised. So it isn't until you start the job that you actually start to take on that responsibility. There will always be some problems, of course there are, but they're facing an environment which is very different from the old days - patient dependency is very high, registered nurse numbers are lower, pressures are on, money is a problem - and nurses across the piece and other health professionals are finding that they're having to do a significant amount more work just to kind of stay standing. BARLCAY Louise Williams was catching up with a couple of people at a conference on nursing in Dublin. Let's take a couple more calls on this issue of training. Sabrina is on the line from Taunton in Somerset. Sabrina, what's your experience, you were a cardiology nurse I believe? SABRINA Yes I was. Well - can I just challenge the assessment the RCN lady made in the beginning saying it's just a media hype which makes complaints against nurses are higher. It's not really, it's the Royal College of Nursing [indistinct words] that there were three quarters of the patients, especially elderly patients, were malnourished because nurses had no time to feed them, would they call that basic nursing care? BARCLAY That's something that we will bring up with Howard Catton a little later on. Do you think that that's down to training problems? SABRINA Yes it is because nursing is a basic need of humanity. When people are ill they don't care if you have a degree or a diploma, they want you to care for their basic needs, as Claire Rayner said in the beginning, that if she was feeling sick she needed somebody to hold her hand, somebody to hold a bowl for her. And that is the basic caring which has gone off. I don't know how the training is now because I don't know about it but I do know when the degree level came in nurses were not coming into the wards until they were in their third year and then they were quite alien to patient culture, they were quite alien to how to deal with people. BARCLAY Sabrina, thank you very much for that. Jill is on the line from Andover in Hampshire, Jill what's your point? JILL Yes hello. I was one of the apprenticeship trained nurses. The thing I want to say is that I was trained as a practical basic care nurse, nowadays that doesn't happen, that is basically why there aren't any - there isn't the good patient basic care because there isn't the specialist basic care nurse anymore. They were dispensed with when - during reorganisation in the mid-1980s. BARCLAY So do you think the training now is too academic? JILL Not in itself but the students do not get the experience of the actual basic hands on care in the wards. BARCLAY Claire Rayner, I know that this is something that you are very concerned about, is it down to that lack of practical experience early enough? RAYNER Very strongly I feel that. They're getting lots of education but they're not getting any training. This is what's wrong. Someone who's a cardiology nurse, fine, she knows everything to do for her patients but if something goes wrong in her ward and there's a flu epidemic and they have to fill in with other nurses who haven't a clue that is useless to the hospital, to nurses themselves and it means bad patient care. ROBINSON Let's bring Howard Catton into this discussion, he's head of policy at the Royal College of Nursing. Well first a reaction from you to the points that we've just heard. CATTON I think one of the things that comes across clearly is the pressure that the staff are under. Nursing staff, nursing still has at its core caring and core skills are a part of nursing education and training, 50% of education is spent in the clinical environment... ROBINSON But is it soon enough in courses? Claire Rayner was suggesting that you do the academic bit first, you may be temperamentally unsuited to holding a bowl whilst somebody vomits but by the time you get on the ward it's too late to change your mind. CATTON I think that you'll find that the clinical component has been brought forward towards the beginning of training ... ROBINSON Toward the beginning, when is that, you've got three years when is towards the beginning? CATTON People have their first experience on the ward in the first year of training and they have clinical placements throughout their training and education programme. And the mistake that we make here is to see nursing just as profession of the heart and of the hands, it has to be a profession of the head, heart and the hands because we are looking at dealing with people with technological issues, ethical issues, managing and coordinating care with very complex conditions. The problem that we've got in the system at the moment are the huge pressures that nursing staff are under, it is true that there have been cutbacks in the number of nursing staff, there aren't enough registered nurses, the mix - the skill mix - the ratio between the number of registered nurses and the number of healthcare assistants has diluted - there are more healthcare assistants than registered nurses. Now if I'm a nurse on a ward if I've got a team of seven or eight healthcare assistants to supervise and to manage then what I'm able to do is very different than if I'm in a team with 60-70% registered nurses and 30 or 40% percent of healthcare assistants. ROBINSON Just a couple of questions that have come in. Are nursing courses over or under prescribed now? CATTON We've just, we've always seen nursing courses being over prescribed, we've seen lots of people who are applying but the last 18 months we've seen the numbers drop and the numbers have dropped because we've had financial problems in the health service, what has happened is that the jobs that newly qualified nurses would go into - band D, band grade jobs - they've not been advertised, they've been frozen, which means that newly qualifying nurses are having difficulty, great difficulty, in getting a job. That means to anyone looking at going into the profession they're thinking well perhaps I won't because I don't want to train and be unemployed. ROBINSON But one point that a nursing education professional, who doesn't wish to be named, has made to us is this that the standard of recruits in the past was boosted by the fact that there very few career opportunities for women so nurses really were a generation or two ago the cream of the crop, nowadays everyone who wants to be a nurse, more or less, can be a nurse if they've got 5 O'Levels and that the deficiencies that are reflected in nurses they're just the deficiencies in us all. CATTON Well look the baseline hasn't changed, you've said it's still five O'Levels, that entry point ... ROBINSON But a woman with 5 O'Levels can do many, many more jobs now. CATTON Absolutely, then nursing - the health service - is going to have to work much harder to attract people in because there are other professions. Which is actually why the arguments say that we should move away from an ambition to have a degree educated profession, is the wrong one, because people in this day and age will want to be educated to degree standard. ROBINSON And just before we go back to calls, do you think part of it is that we are all less caring now than we used to, in the sense that we live on our own, we're not used to helping elderly people get dressed etc. and therefore if nurses recoil at some of these tasks they just reflect all our attitudes? CATTON I think there's important point in there, I think there are so many people other than nurses who are involved in nursing - families, relatives, friends are all involved. And we all have skills and understanding about what nursing is. But I think the problem is we don't seem as a society to value and recognise how important caring is and that I think your link with gender is where there really is a link that historically those roles that women have undertaken, which are caring roles, have not been as valued as highly. ROBINSON Claire Rayner, very briefly if you would. RAYNER I must say that we used hands and heart but we used our heads just as much. We did many of the tasks you describe, certainly by the end of your second year you were starting to behave and learn and react to patients as you had seen the juniors couldn't, gradually were coming up. Training is so different from education and people must work out what matters more, I think training does. ROBINSON I need to just interrupt here for an e-mail. Olive from Bexley has e-mailed to give an illustration of what targets mean in practice. She says: We use something called the Warrington scale which, for example, allows you 15 minutes to administer insulin and take a blood sugar level. We are allocated a certain amount of units a day in the community, so if there are problems and you encounter problems you simply do not have time. Budgets and targets - that is how they work. CATTON And that is exactly - that's a classic example of how we don't value and rate care and we try and break everything down into tasks that we can easily measure to try and apply techniques from industry, productivity measures - we're talking about lean methodology from Toyota now being applied to the health service. You cannot - and I'm not saying there isn't a place for good management in the health service, of course there is, but you can't fit people into neat little boxes which says that you will wash them in 10 or 15 minutes, they just don't work that way. BARCLAY Well lots of the calls have been reflecting lots of the points that have been made. Derek Bradshaw is on the line from Salisbury. Derek. BLACKSHAW Hi it's Derek Blakeshaw. BARCLAY Oh I'm sorry. BLACKSHAW That's okay. I want to introduce a fresh angle on this. I do so agree with what Howard has just been saying though, I think the training now is superior in understanding to the training that I undertook in the mid-1960s. But what is not superior is the training in the delivery and the understanding of the delivery of care. But the fresh point I want to make is that nurses are no longer in charge of their area, their authority to control a ward has been taken away from them by successive changes in the health service. Each change has been small but if you look at things like the names - there's no ward sister, they're called the administrator or ward manager. The healthcare support worker, no longer the nursing assistant. The nurses ... BARCLAY Why do you feel that makes such a difference? BLACKSHAW Individually these things don't make a difference but what has happened is that the authority of the nurse to control the care area has been removed, they're no longer responsible for the cleaning of the area, though in some instances that's coming back because of the problems that have been found with the new systems of cleaning and the contracting out. They're no longer giving the food to patients, more importantly they're no longer clearing the plates away, so they don't see what the patient has eaten, they don't understand what that patient's nutrition has been that day. And there have been so many more things introduced into a ward that the nurses are no longer in a position of authority or control. I had recent experience of my father being in hospital, there were many things that were wrong with his care but looking at what was wrong, looking underneath, the things that were wrong were only the symptoms of a malaise and the malaise was that there was no controlling presence of the ward. BARCLAY That is an interesting point which we will discuss with Howard and Claire just very shortly. Let me bring in Fiona Sample who's on the line from Northumberland. Fiona, what's your experience? SAMPLE Hello. Well very varied. I've had two and a half years while my husband's been treated for cancer, so I've had personal experience but it motivated me to join a patient and public involvement forum and I brought out a paper on nurse to patient ratios with their backing and help because it was very evident to me, coming from a background of teaching, that there was no statutory limit on general wards to the number of nurses to patients and that this actually was the central point in what I observed in the varying treatment we got. Very few nurses go into nursing who do not care but many become quickly disillusioned and dispirited. BARCLAY What do you think of that point, that was just made about nurses no longer having control? SAMPLE I think that's a very valid point, there seems to be nobody in command, that the image of the sister in certainly several of the hospitals we were in seems to have gone, though one if she was there and ruled with a rod of iron then the ward was immaculate. But patients are assured the best outcomes and there's been a lot of research done, if there is a registered nurse ratio of one registered nurse to four patients, that is absolutely the optimum level. Anything beyond one to eight and the statistics of failure to rescue and recovery zoom up for every additional patient on the nurse's load becomes positively dangerous. And I can't understand why there isn't a statutory minimum level on what one has to call general wards. I know that intensive care units and high dependency units have them but let's say in a nursery there has to be - for two year olds there has to be four children per one adult, three year olds the same and four year olds one to eight - I mean surely people in hospital are more vulnerable than the average four year old in the nursery situation. BARCLAY Well let me bring in John Morgan from Southampton on that point. John, I believe you're a nurse in an intensive care unit. MORGAN That's right and on top of that I only qualified in 2001. So I just have to say that, and it's been affected a little bit by Claire, I and my colleagues we're in what is generally regarded as the technical side of nursing but that in no way detracts from the level of fundamental care that we give to our patients. Patients are turned regularly to prevent pressure sores and all of our patients, everyday, sometimes two, three times a day, are washed with sheet changes to make sure that they are comfort - comfortable and that they maintain their skin integrity. BARCLAY Fiona was saying that there isn't a statutory nurse/patient ratio except in intensive care - is that the case? MORGAN In intensive care if a patient is ventilated then - in other words they're receiving mechanical ventilation - then they will - I'm sorry mandatory ventilation - then there is a patient to nurse ratio one to one. BARCLAY So surely that makes it much easier for you to carry out then the caring part of the job? MORGAN That's - yes that's fair at one level, at the other level intensive care is called intensive care because the people within it require intensive nursing and so their needs, the needs of one particular patient, are very, very complex. BARCLAY John, sorry ... MORGAN Well I just want to say that our skills, using hearts, minds and hand, are best embodied where we work. We have to interpret blood results, we have to interpret arterial blood gases and we have to act pre-emptively as well to prevent any sort of deterioration. And on top of that we have to provide fundamental care and we do that and I'm saying that I'm part of a team, we all do that within my unit. BARCLAY John, thank you very much indeed for that call. Claire, obviously in intensive care that one to one ratio is required, do you need a nurse/patient statutory ratio throughout hospitals? RAYNER Oh you do. What do you mean general hospitals? BARCLAY Yes. RAYNER Well not one to one, that would be extravagance, wonderful, but too much time with nothing to do for the average patient. But there should be an awareness of which patients need the most care so that - I mean in the old days, which they don't do now, patients at the very bottom of the scale used to knock in - give out afternoon tea or something, it was not unusual. So that they supplemented other areas. But it would be nice if you didn't have to ring and wait for 20 minutes of constant ringing before somebody acknowledged you were there. BARCLAY And Howard Catton, what about this whole issue of lack of control on the wards by the senior nurses? CATTON I think it's an absolutely fundamental point that Derek makes, that if you look at areas where - which deliver high quality care they've got strong innovative clinical leadership. And some of the problems we've seen in the past is that those leadership structures, those career structures for nursing, have been taken out and have been replaced by general management. It's not an either/or, it has to be a partnership. And interesting that the government now are talking about the fact that they need to have a better discussion and conversation with clinicians to find out what's happening at the front line. But the point about ratios is also hugely important, the numbers of registered nurses to patients and the number of registered v non-registered healthcare assistant staff. Whereas in the past we'd make the case for nursing because they cared and they were important people you can now make a strong business case for nursing. The right numbers of nursing staff mean that people get better quicker, they have higher quality care and actually at the end of the day there's now evidence to show that less people die, so there is a hard strong business case for nursing which we need to be and are advocating now. BARCLAY Let me bring in Eileen Chitty, who's on the line from Reading. What's the situation, Eileen, I think you know about the situation in America? CHITTY Yes I do. Unfortunately I've spent some time in hospital over here but last year I spent five days in intensive care in Washington. And I found their care absolutely unbelievable. BARCLAY In what way? CHITTY You had a nurse with you the whole time and I mean I wasn't at the point of sort of needing a respirator or anything like that, I was on an insulin drip, but she was with me the whole time and she was totally focused on my care, to the point of they only provided tea, so she went and got me my own coffee, she brought coffee in for me. BARCLAY To what extent though do we put that down to the insurance based system that exists in the United States? CHITTY I'm sure it has a lot to do with it but at the time - I mean I was out there on holiday staying with my daughter for three months and my insurance had a problem, so they didn't even know if they were going to get paid when they were treating me. And they were just absolutely fantastic, I mean it just seems like - one day she said to me: "Would you like to have your hair washed?" And I said well have you got time, being British, you know, have you got time. "Yes I'm here with you." BARCLAY We're very pleased to have you back in this country and recovered. Let me just get in another caller. Richard Stern is on the line from Glasgow. Richard, what's your experience? STERN My experience has been varied but all I can say is I wish Claire Rayner well and I wish she was my nurse today. Let me just say that 32 years ago I unfortunately took ill and I was on the spinal injuries unit and the nursing care was absolutely superb. We never actually had hospital borne infections like we have today, not to the same extent, you know MRSA is a very, very serious problem and it's due to very bad nursing care and bad standards on the wards. And all I can say is I've already lost a toe and I'm about to lose another one through MRSA and this is completely unacceptable... BARCLAY Richard, I think both Howard and Claire have thrown up their hands in horror at the idea that it's bad nursing care. I just need to get a very quick comment on that, to Claire, very quickly. RAYNER It was lack of hygiene everywhere in the hospital, simple as that. CATTON And we need to stop saying it's down to one professional group, if you look at the problems around infection control we haven't got enough cleaning staff; hospital design is poor - we haven't got enough single side rooms; we need to change the way that we prescribe drugs; we need to have better screening. And I'll go back to the point about the systems running hot at 95% plus, we need to give people time to care. BARCLAY And there we have to leave it, we've run out of time for your calls. ROBINSON Yes that is it, apologies if we haven't been able to answer your call, I think it's fair to say that this discussion has attracted more calls than probably any other that we've done, certainly in the recent past. Most of the calls we received were personal horror stories, one from a patient who had water spilled on him just after a spinal operation and says he was left in that cold water for three hours. But a significant number too were praising nursing staff. David Lyndmore from Essex, for example, says that he encountered a ward manager telling nurses to treat the patients as they would treat their own parents and he says they certainly did. Many of you feel that nurses are abandoning their caring roles, some of you believe this is because of pressures on them, some of you mentioned new administrative duties, some of you mentioned a shortage of staffing and time. One text said: This nursing station always seemed to attract a lot of doctors and nurses and it was very hard to get them away from there and when you stopped to listen they seemed to be chatting. Our guests are desperate to respond to that. Now just one final thought as well, one of the new health ministers, Ann Keen, is a former district nurse, she says she is only one of two who've made it to the House of Commons and perhaps that will make a difference, we'll see. RAYNER I always said that the nursing station is the worst invention, terrible. BARCLAY I suspect we'll get a few more comments on that. Thank you very much indeed to everyone who called and I'm sorry if your call didn't get on air. And thank you to Claire and to Howard. Back to the Transcripts homepage Back to the You and Yours homepage The 大象传媒 is not responsible for external websites

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