Another rant about nurse education

I have to say, looking back over my recently-completed nursing degree, I think I’d had an excellent education over the past three years, and just about everything I’ve been studying has been really relevant to clinical practice.

I think my syllabus could have done with more anatomy/physiology and pharmacology lectures, but to be honest I found it much more effective to learn these subjects out on the wards, seeing them being used in a real-world context. Stick me in front of a death-by-powerpoint presentation reciting long lists of medications, and I’ll simply nod off. I learned far more by looking at some of the medications I was giving out, and when I spotted one I didn’t recognise, grabbing a BNF and looking them up.

I learned far more by looking at some of the medications I was giving out, and when I spotted one I didn’t recognise, grabbing a BNF and looking them up.

That’s pretty much the best way to do it, to my reckoning.

You need the lectures to have the grasp of pharmacokinetics and pharmacodynamics and rationale behind regimens and augmentation strategies and the like.

The sharp details, though, that’s gained through experiential learning as we and our patients witness the effects (good and bad) of medication and consolidate this through bouncing discussions off peers and hitting the BNF or other books or t’interweb.

I found it was only on seeing psychotropics and then reading about them that I got the sense of perspective and context (e.g. on how much a drug was sedating or caused weight gain or disturbed sleep or ruined sex or provoked nightmares).

And even now with newer drugs it’s mostly me and my patients together who teach one another about the new drugs rather than slick presentations or drug reps or whatever.

“on Dr Rant, there were a couple of posts from nursing blogs, one of which - it was purported - was about the parlous state of nurse education. It was, in fact, a moan about some tedious training provided by a medical devices company about how to use one of their products.”

Before going off on a rant it might have been useful if you had actually read the fucking post that we linked to:

“When I think back over what I have done I soon realise just how irrelevant the training of today’s nurses is. I used to think that this was simply because they were trying to make nurse training as far removed from the real world as possible and wanted students to have no clue. Seriously, the most progress we made was in the last half of second year when we were being groomed for the critical care placement and were expected to actually know something about the care of patients. If you look in the dictionary, the definition of nursing is to aid people’s recovery through periods of illness or infirmity and help them meet needs which they cannot meet themselves (see the Roper Logan and Tierney 12 activities of living).”

and

” No wonder nursing is so disorganised and shit this day and age. I happen to know a fir bit about anatomy and physiology. I spent time studying ambulance aid so know of fractures, cardiac conditions, spinal injuries, the systems of the body, and read up on drugs. In the nursing school, none of that was considered important. BASIC NURSING CARE! Where was that? BASIC does not mean the same as SUPERFICIAL. Though maybe that’s typical of the glamour obsessed self serving tossers who are considered “too post to wash” when back in first year I went through 4 vomit bowls brimming with sick to recover a patients lost dentures (which were actually in another vomit bowl back in the bay), yesterday was racking through a bedpan full of loose stool to do a sample and dredge paper from, then did the same for a urine test. Hardly glamorous but then I am a mildly pudgy bloke who wants to genuinely help people. Some nurses must be females who are living in some pink and blond valley in California who must be living the “hello!” celebrity culture who think that doing bed baths, checking observations, doing aseptic dressings, taking BM, Blood’s, care of central lines, catheter care, dealing with relatives, talking to patients and working with the doctors and possessing a nursing and medical knowledge base not glamorous enough. ”

Mrs Rant is currently doing a ‘return to practice’ course having been out of nursing for four years. Her view? “It’s a load of fuckwank”.

I agree with her. You can get your head up your own arse as far as you like, but it won’t change the fact that the secret of nursing a patient is to nurse the patient.

The big question being asked by experienced nurses is: is it nurse:patient ratios, or is it that modern nurses are just shite?

is it nurse:patient ratios, or is it that modern nurses are just shite?

I can only really comment ’bout mental health nursing. Our Trust has closed a lot of wards (3 in my Directorate alone) so the wards we do have left have pretty ill and distressed folk not as part of the ward but as all of the ward.

Nursing staff are now much busier, managing a much heigher proportion of seriously ill patients on each ward.

Managing a psychiatric patient is not about drug treatment. We know that before drugs in-patients got better (mean duration 2 years) and usually medication helps the process of recovery rather than is the process. As such, skilled nursing care to help patients with distressing experiences and de-escalating aroused patients before they clock someone takes time.

When I consider changes in management I want to know the nursing observations. What behavioural repetoire is causing concern? When does this occur, just with personal care or just in public or just at night, what are the precipitants? I want to know about prosocial and antisocial behaviour. I want to know if there are biological features of mood disorder. I want to know if symptoms and signs are persistent and pervasive. Nursing staff need to actively glean this information and document it. This takes time.

1) In-patient assessment can consume vast amounts of a qualified nurse’s time in a shift.

2) De-escalating risk can consume vast amounts of a qualified nurse’s time in a shift.

3) If things “kick off” on a ward then several nursing staff are required to deal with volatile situations safely in order to restrain a patient and administer medication then talk through expectations and the immediate/short term future.

Just these 3 things alone necessitates a minimum staffing level. With a high proportion of disturbed folk on the ward, that staffing level has to be higher now than it was 5 or 10 years ago.

To my mind in mental health nursing it’s got nothing to do with quality of nurses and everything to do with having sufficient resources to address my in-patients’ clinical needs.

I can only speak for my own nursing education, but I can only say that my recently-completed nursing degree (which I passed with first class honours) certainly did not prepare me to be “too posh to wash”/”too clever to care” - quite the opposite in fact. I think my new team would be amazed if anyone suggested I was too posh/clever to bath a patient, make them a cup of tea or wipe their bum.

If I’ve learned anything in the three years of training as a mental health nurse, it’s the vital importance of getting out there on the ward floor, engaging with patients and developing a relationship with them. We’ve had this drilled into us time and time again while at university. The main thing that keeps us stuck in the office and away from patients is most certainly not that we’ve educated into thinking it’s beneath us to interact with smelly unwashed patients. The main problem is the never ending-streaming of phone calls and paperwork that prevents us from leaving that office because you’re the only qualified nurse on shift and there’s nobody else there who can do it.

That said, I firmly believe that with effective time management (a skill learned at too-posh-to-wash university) on my ward it’s possible to *find* time in between all those to engage with patients. This may not be the case on a hectic acute ward that has just had its patient mix drastically change because all the less acute patients are now being managed by the crisis team instead.

Dr Rant, I refer you to Beakie nursing degree syllabus that he’s listed above. Would you kindly point out which part of it is the “load of fuckwank”? Is it the “Sciences for nursing (anatomy and physiology, sociology, psychology as applied to nursing)”? Or the “Two modules looking at biopsychosocial factors in the causation of a range of mental health problems from schizophrenia to ADHD”?

My, my, for someone who makes lots of acid comments about “fuckwank” Dr Rant seems remarkably fluent in the language and thought processes of “fuckwank”. And Beakie, “self-righteous iindignation” is one of my favourite expressions (as well as one of my most daemonic bétes-noir). My eternal hope is that the purveyors of self-righteous indignation will eventually dissolve in their own bile.

I’ve been facilitating a “service user perspectives” session at a local nursing school for about 7 years now, final year acute adult MH students. The vast majority of them are keen as mustard to get out there and use their clinical and interpersonal skills to help the people who they enrolled themselves to help. This laudable attitude seems to be on the increase, which I find heartwarming. I’ve been known to get down on my knees in these sessions and plead with them to not let the environments (and sometimes cultures) they work in rob them of their enthusiasm for proper nursing.

My overall point is that whatever is wrong with a system it’s unlikely to be solved by knee-jerk blame-mongering of the people within that system who are actually trying their best to deliver what my own “service user perspective” requires: compassionate professional care.

Are modern nurses “shite” ponders Dr Rant - well, no, is the short answer, although nurses must soon get used to cleaning up shite, and I’m thinking about much more than the physical act itself.

“The secret of nursing is to the nurse the patient” Dr Rant maintains - an apparently unarguable proposition one might think, and absolutely correct too……. but only to a point.

Perhaps the medical analogy would be “the secret of being a doctor is to diagnose and treat patients” - but what percentage of medical work falls beyond this remit, if we accept that a huge proportion of what doctors do [especially in general practice] is actually concerned with problems in living rather than pathophysiology ?

I daresay some nurses long for the luxury of simply being able to nurse the patient.
But in my view it is the pragmatic needs of patients that must ALWAYS shape what clinical staff do, or in other words why should docs/nurses have the luxury of non-negotiable job demarkation ?

Take A&E - an elderly lady falls on the way to the loo in the early hours of the morning. Clinically she has a fractured wrist, which may be slightly deformed.

Nowadays triage nurses can;
*provide analgesia under a patient group direction [PGD] - but isn’t this prescribing in all but name ?
Surely the old system was far better when the triage nurse had to hunt down a timid SHO, spend 10minutes explaining the story/explaining relevant history, etc only for the SHO to prescribe paracetamol anyway [having never examined the patient] - certainly the Jonahs of the day insisted that patients would be dropping like flies if nurses were suddenly permitted to dole out drugs without discussing it with a doctor first.

Triage nurses are now authorised to make radiology requests - but isn’t this is quacktitioning of the first order ?
Surely it is far safer to leave patients in the waiting room [even if the waits are for many hours] rather than some wannabe doc initiating a commonplace investigation that might improve the situation for patients and clinical staff alike ?
Incidentally most doctors don’t seem too keen on the idea of a minimum standard of a 4hr wait either, but I digress.

Perhaps we can return to the original propostion [nurses, nursing the patient] - well it doesn’t take Einstein to work out that by stripping nurses of ‘extended roles’ [at least in A&] we will have lots of elderly patients in the waiting room all of whom are now at risk of developing pressure sores [providing they haven't bled to death from a leaky annyeurism first - blimey that might require nurses to cannulate, didn't that used to be something only performed by doctors too ?]

Yes, by turning back the clock nurses now have a glorious opportunity to institiute meticulously planned pressure relieving interventions [regular turns/sacral padding, etc, etc] - the ying/yang and traditional boundaries of nursing and medical roles having safely been re-established.

Actually, I’m simply observing this debate.

It was my wife, an RGN with a degree and a diploma in Health and Social Welfare (IIRC) that described the back to nursing course as ‘fuckwank’. I have asked her to write a piece for us, but she is too busy reading books about the illness client interferce as it relates to the witch doctor within his own cultural frame of reference. Or at least that’s what I think she said. She was foaming at the mouth at the time and had me backed into a corner with a heafty copy of Bioethics, so it’s hard to be certain.

As for the idea that modern nurses are ’shite’, this is not my view. Personally I think the problems are politicians keen to dumb down care and low staff:patient ratios. What I said was that many of the experienced nurses that I spoke to thought that modern nurses were ’shite’ (actually, that’s a bit of poetic licence - the comments ranged from unprofessional to lacking proper training to using nursing as an ‘easy’ entry stepping stone degree).

It was the nurse tutors at the university that told me they felt their student nurses were coming out of their training without the required skills and that the course needed to be changed (to make it more practical).

To accuse me of taking a ‘them and us’ approach, when I’m simply writing about what nurses themselves have told me, is clearly the opposite of the truth.

Much of this debate reminds me of a recent ward round. The consultant psychiatrist was discussing the current training of doctors. She felt there was a generational gap between the older doctors, who thought the current training was far too touchy feely instead of dealing with the nuts and bolts of diagnosis and medication, and the younger doctors.

Yes, I understand the ‘old guard’ mentality that leads to criticism of new recruits.

However, unless the research has been repeated recently, there is no way for you to know whether this is indeed the same self-perpetuating meme or something new.

Certainly, I’ve listened to more senior nurses talking about junior nurses since the mid 1980s and I’ve never come across such frank or shocking comments before.

Also, in the 1970s patients were not complaining en-mass about poor standards of nursing and nurse training had not undergone the same dramatic changes as it has since the late 1980s.

So I think it is dangerous to dismiss this.