The worst thing about taking a holiday, is going back to work! Emails, post (nicely sorted of course I am not without admin support), work you have forgotten you should have done already. The best thing is people coming up to you and telling you that they have missed you, yes really it happens and not because I am quite loud and therefore people notice my absence!

The emails weren’t too bad, only about 60 or so and some of them were HSJ alerts and the like. There were only 2 messages on my ansaphone and my post folder wasn’t exactly bulging (though it comprised mainly of invoices so no change there). On the other hand it was quite nice to see everyone, to chat about the latest developments (not nearly enough I am sorry to say) and to actually do some work (yes really).

I spent the morning appraising one of my team, I quite like the quality time I can spend catching up with progress and events with people who are still doing a great job out there. Supporting students and mentors is a really important job and not enough people recognise just how vital it is to be around to pick up the problems that occur with students. It is only too easy to criticise standards, but there are people out there trying to make sure that we turn out some half way decent nurses.

Tomorrow I have a late start as teen son has his dermatology appointment, and it was too complicated to get the receptionist to find us an appointment time that was convenient to either teen son or me. i.e. one that didn’t require missing work or school. Still I’ll make up for it on Thursday when I am going in for an early meeting, which will mean leaving home at 7 or something. Bring it on!

The news story this week that nurses and doctors may still be crushing tablets and giving them to the elderly and anyone else unable to swallow a tablet has got me thinking about the early days of my nursing career when I was young and yes innocent too. We all were, nurses were still ‘angels’ and not of death, they worked hard, did as they were told, and nurse practitioners were still a twinkle in the eye of the degree level tutor. Oh yes, even in 1980 some people were already daring to take a degree in nursing, not me though I was a proper nursing student, one who worked all shifts and 1 week in 4 of nights. Degree nurses had to do a 4 year course because they needed that amount of time to get the hours of practice in.

There were some interesting things about the drug round when I was a student and indeed after I qualified, we had a pestle and mortar to do the crushing and we had jam to mix it with. We actually disguised the disgusting flavour for the poor unsuspecting patient! We also had whisky, brandy and sherry on the drug trolley, which we administered mainly on prescription - yes the doctor wrote the stuff up. I remember on nights trying the quality of the sherry, and it was not something you would want to make a habit of (not just because you didn’t want sister to find you doing it) but that didn’t put the patients off!

The wards in the early 1980s were literally run by students, the third years were in charge pretty much and it seemed to us that the staff nurses spent a great deal of time in the office with the doctors. Sadly this proved to be less common once I had qualified, or perhaps I just worked on too busy a ward! At night it wasn’t unusual for 2 students to be alone on a ward caring for 20 patients with night sister popping by to check on us and to give any iv drugs. We got on with this because it was normal, we never questioned the wisdom or the danger the patients might be in, even when one night I ended up having to put my fist into the groin of a patient on orthopaedics who had eroded his femoral artery. Mind you I got myself a date on the back of that - a young man recovering from a motor bike accident who was impressed with what he saw and who asked me out for dinner when he got out. It didn’t last past the first date, but was fun!!

The doctors went round in huge packs (The Firm), this was a teaching hospital so you had numerous registrars, house officers and students. This didn’t stop one SHO working out how to insert a supra pubic catheter from a book. If he could have got away with getting the staff nurse to hold the book while he actually did the procedure he would have. Many of my friends went out with medical students, I restricted my self to late night meals in the doctors mess canteen with them and drinks in the local pub.

We all lived in the nurses home, the one I lived in was for girls only and was run with an iron fist by Miss Bender reputed to have been a ward sister who had been retired for being too nasty to the patients. She was always on her guard for any male visitors and wasn’t averse to coming into your room if she thought you had one in there after midnight! We used to smuggle boys out by taking the lift to the basement and using the tunnel system to the hospital. Indeed we used the tunnels a lot, in winter you could do a whole week of nights without seeing the light of day or actually going outside. We must have been a pastey lot!

For all of this, we became nurses who knew how to nurse. We learned good basic care, we learned about disease processes and we learned about communicating with our patients. We worked hard but we had a really good time. We were innocent, we knew what nursing was, our patients knew what to expect from us and pretty much we delivered. I fully support nurses being better educated, not everyones training was as good as mine. We had the luxury of the medical school being around the corner and had brilliant lectures from doctors as well as nurses. When I moved to the suburbs I found that not all nurses were trained the way I was, they had a lower level of theoretical knowledge and were less skilled in nursing care than I had been used to. Things had to change. I am not sure that the nursing courses of the 80’s would be fit for the expectations of 2006, but sometimes I do wonder!

Pretty much that is what I didn’t like about yesterday’s trip to Thorpe Park, it was very busy and a lot of queuing was involved. The kids had a great time though, and the most daring of the 3 was Laura who is 8 and luckily as tall as your average 10 year old so not turned away from any ride. We didn’t get to the spooky, Halloween mazes as there was a 60 minute wait to get in and they preferred to queue for things that they could see. Once it got dark at about 6pm the rides felt quite different and actually I think I prefer it (no need to close my eyes quite so much so that I can’t see the ground speeding towards me)!

This morning I am quite exhausted and I can see motivation for doing much today will be a challenge.

Thirteen Random thoughts for this week

1. Autumn is arriving late this year. As I sit in bed typing this, and look out of the window, the leaves on the trees are more green than brown and they are still there.
2. The strange seasons this year is going to cause Christmas to creep up. I am on the case though because I intend to buy a few early presents over the weekend and get ahead of myself!
3. I am relieved to be having a few days holiday from work, I hadn’t realised how tired I was feeling until I had little energy for anything yesterday. I spent more time than I should have done surfing. I managed to get a pile of ironing done though so all was not lost!
4. Today I am taking 3 children to Thorpe Park, my brother has chickened out, claiming lack of sleep having not got in from work till late this morning, but I am still up for it. I have taken various of my nieces and nephews on lots of trips like this over the years. I will be sorry when I have no one to do these things with any more!
5. Teen son has been in my bad books over the last week. On Friday night he said he was staying over at a friends and then turned up at 12.45am having walked a couple of miles home! He tells me I shouldn’t worry  - easier said than done!
6. I am taking him for his dermatology appointment next week, the effect of the roaccutaine has been nothing short of miraculous and he is more confident for it. I am suspicious that there has been recent girl activity but no hard facts yet!
7. It is official I am now old. I had an eye test yesterday (following the fuzzy situation) and it is time for the reading glasses / varifocal thing. I have also turned short sighted in one eye having always been long sighted in both. I am definitely becoming most weird (you don’t have to agree with this statement). The monovision thing with the contacts is improving though and I am no longer a danger (in my own opinion).
8. I have reading to do for my next assignment, but haven’t quite got myself in the mood for it yet. I have a whole day at home tomorrow so perhaps should put that on my list of things to do. Perhaps the list should contain the things I shouldn’t do, like spending too long blogging and looking at other peoples very interesting blogs!
9. Apparently things at work will be sorted out by Christmas, well in terms of job allocations. Some things, like appreciating the full effect of merging people together, will take longer to sort I think. Plus I think we can write 2006/7 off as a year spent doing much other than trying to save money.
10. I am back in the swing of blogging since I changed from blogger to wordpress. I am still thinking of getting my own domain so that I can use wordpress to its full effects, but at the moment I think things are fine here.
11. I am writing more about NHS / work related things, but then I am finding I have more to say about those things. But that won’t stop be writing about everything else that is happening in my life. I like a bit of balance you understand.
12. Nearly every day there is some kind of healthcare related story on the news, usually criticising something (or lots of things) currently being done by Doctors, Nurses or others. I wonder sometimes about the motive for this, and whose agenda this relates to. Today it is about crushing slow release tablets, something all nurses who knew no better at the time are likely to have done. No excuse for it these days as things are better labeled and you would hope people understand more about the effects of this practice.
13. Well it is now time I got on with things here, I have lots to do before we go off on our day out and this won’t get it done! I will report back on the days events tomorrow!

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I have some vouchers collected from a newspaper (not my usual read, as it is very low grade you understand) so that I can obtain a 2 for 1 type deal for some of the UKs top attractions. I have decided to take teen son and 2 of his cousins (their dad is also around this week so will come too) to Thorpe park. Because it is half term and because it nearly Halloween they have special events this week, so they want you to prebook your tickets and if you pre book, guess what, you cannot use the 2 for 1 vouchers. Now I am in no way tight with my money, otherwise I would not have the debt I have, but £114 or £76 what would you choose.

We are going to take a chance, lets hope we return with children who are tired out and have had a great time, not ones who are disappointed!

That all nurses want to be specialist nurses or nurse practitioners and if they do who is leading them into this false dawn? This is the question that has been troubling me over recent days, when I am not fretting over the future of my own job that is!

Yesterday I met with the two people I am mentoring (management and leadership wise) through a Community Matron course and their tutor to go through the competencies they need to meet as part of the course and how they will be able to do this. Our PCT has been slow to introduce this new role into our area and we have been penalised in the latest round of brownie point awards for it. But we have wanted to make sure that we know what the role should be locally and that all of our nurses working in the community know how to care for all of our patients. All district nurses are specialists in community nursing, they have specific skills in wound management and palliative care and are often referred to as specialist generalist.

That is not to say that case managing patients with highly complex needs is not important, because it is, and that is also not to say that we don’t want to prevent these patients making unplanned and unnecessary visits to the local hospital.

Sad to say, but one of the underlying reasons for this is the state of our local acute NHS trust. This is an organisation that has suffered poor staffing levels, poor management and leadership and poor financial management for a number of years. In the past they have sourced the world for nurses to recruit to their ailing numbers because those who trained locally would not work there if they had a choice. I have no first hand knowledge of their nursing care because thankfully I do not live on its doorstop, but I have heard stories which would make my hair curl if it wasn’t already curly. They have nurses for practice development, experienced nurses whose job is to help those on the wards to develop their practice, they have implemented essence of care (ridiculed, but a way of getting those who know no better to learn how to do things). They have specialist nurses, people who advise on infection control, those who advise on wound care and many more no doubt. But they seem to be unable to improve things. Now they have serious debt, so where vacancies existed there are just smaller ward establishments so it is really hard to see how they can improve. For us working in the community all we can do is feed back their short comings and to try to stop patients who could be cared for at home going into the place and to do that we need to have staff with a wide range of skills.

We do not have lots of specialist nurses, we have Macmillan nurses (who provide cancer / palliative care) and we have some people concentrating on diabetes and also therapists who specialise in neuro rehabilitation. We are cautious because we want to make sure our staff recognise that our patients need more than specialist care. It is an uphill battle I can tell you.

Anyway, back to my meeting yesterday where we discussed how the two nurses can obtain the experience they need to meet their course competencies. Both have GPs as medical mentors, willing to share their knowledge to teach our nurses new skills. Both are prescribers but do this cautiously too, they want to work with their GP colleagues not go off as some kind of maverick, saving lives and getting up the backs of our medical colleagues. OK so I am painting a Utopian vision that is not the whole reality but sometimes good practice does happen, it just doesn’t seem to be reported in the blog world or anywhere else.

Please note that half this post went missing into the black hole of the WWW if it in anyway doesn’t make sense! Blogging is fun, but at times hugely irritating!!

Work is quite a depressing place, and today morgue like, though the car park was quite full so maybe they are parking their cars and going shopping or something. The new organisation is 23 days old but still we wait patiently for proper instructions, today the finance team apparently ‘closed the books’ of the old PCTs, we wait to hear the bad news on that one!

I think all this uncertainty is beginning affect me, I am a little irritable with my menfolk. I had a bit of a turn tonight over the chores (which all seem to me my job) and the conversation at the dinner table (lacking). I have a few days off after tomorrow so that will cheer me up (well lets hope).

Tomorrow I am meeting with my team to discuss the proposed structure for education in the new PCT. I don’t know which of those on offer is mine (though I can take an educated guess) or if they will still be my team by Christmas. Still I have my Agenda For Change banding and that is a slight improvement on the previous offer so I guess there is a silver lining, I just need to recognise it.

It would be true to say that there has been a near explosion in nurses working in more specialist roles, moving themselves from the generalist basic bedside level, within both primary and secondary care. The word nurse is a protected title, if you aren’t one then you cannot pretend to be one, but if you are already a nurse, then there is nothing to stop you or or employer calling yourself a nurse practitioner and that is in my opinion where the problem lies.
“A Nurse Practitioner is a nurse who is responsible for autonomous clinical decisions, who uses skills not usually exercised by nurses in differential diagnosis, screens patients for disease, develops preventative care management and who may refer or discharge patients.”
The RCN original definition of NP practices defined by the RCN in 1996 is furthered and detailed in its more recent publication (001797) July 2002 (revised 2005).

The RCN or Royal College of Nursing has a vested interest in maintaining (or perhaps the way things are going) restoring the good name of nursing, so suggest that in order to become a nurse practitioner, you follow a specifc programme of study at BSc or MSc level which gives you the appropriate skills. However they can do little more than suggest, as at present the regulating body for nursing the NMC does not actually recognise or record the qualification separately.

So what does the course involve? Well, one I found for the University of Swansea in Wales offers a course comprising as follows:

“The course commences in October runs on a part-time basis of one study day per week over two years, followed by the dissertation year. Please note that this does not include the one year prerequisite pre-clinical year . Some modules may be delivered in a block form, however students will be advised of this in advance.”

Modules

Part One - years 1 and 2 (part-time)

90 Credits would be compulsory as outlined below

Compulsory modules

Clinical Supervision

Clinical Assessment Skills

Clinical Assessment Skills 2

Clinical Portfolio 1a and 1b

Research, Information and Knowledge Development

Consultation Skills

Optional modules

Students can opt for any combination of approved modules that total a minimum of 30 credits from the School’s module catalogue.

Part Two- year 3

Clinical portfolio dissertation

Students who achieve 60 credits on the course will be awarded a Postgraduate Certificate, those who achieve 120 credits will be awarded a Postgraduate Diploma and those who complete the full programme obtaining 180 credits will receive the full award.

As education manager, I have provided funding for many people to do this kind of course and so far they have mostly been practice nurses who are taking on a more advanced role within GP practices, and more recently we have sent a number of district nurses on a community matron course which is post graduate and is a years duration which will be probably followed by further study in specific areas like COPD or Heart Disease.

Sadly some nurses act under the misapprehension that a short course in developing specific clinical skills makes you in some way a ’specialist’ or a ‘nurse practitioner’, this is not the case, and even if a nurse takes part in a long course, it is not going to be that which makes her into the competent practitioner. Clinical practice is where you apply new skills, it is where, under supervision, you learn how to actually do it and to recgnise how theory is applied in practice. An employer who does not recognise this, is doing both themselves, their nurses and doctors and indeed their patients a dis-service. This seems to be how we have arrived in a situation where people appear to go on a short course and return with the title ‘nurse practitioner’.

I would like to see some kind of advanced nurse role being registered with the NMC, so that people could tell what gave that specific nurse the right to call themselves Nurse Practitioner or Specialist, but although this has been consulted on by the regulator, so far there has been no concensus or decision and perhaps this is adding to the confusion. The other problem is that nurses appear not to want to actually do basic nursing and that is less about ability and more about the type of people who are being chosen to be nurses by universities, but that is another issue entirely!

You can find the RCN guidance on Nurse Practitioners here, you will need Adobe to so as it is a PDF file.

Let the debate begin!!

In more way than one, I can tell you. Life is confusing enough around here, as we wait for our jobs to become ‘at risk’ while we apply for the jobs that best fit the one we do now without living in something in a real fog. Its my age you know, something that seems to happen to us all in some way or other and in my case it means that I have been having trouble seeing my computer screen and books etc with my contact lenses in.

I am long sighted, more in one eye than the other, and the discrepancy in my two eyes makes contacts my preferred method of seeing clearly. My contact lens practitioner was sympathetic to my plight when I saw her a couple of weeks ago and said she could change my lenses so that I use one eye for distance and the other for close up. The close up part is fantastic, things are looking wonderful, it is the distance that is now a big problem and particularly after a long period in front of the computer at work, I am now a danger to life and limb while driving home. Well I would be if long periods of my journey weren’t spent in a traffic jam, but that is another story!

Apparently, and this is both from a conversation I had with the contact lens lady on the phone yesterday and a google search last night, monovision can cause problems with distance vision, particularly for night driving, it can also affect depth perception and I have enough problems with that already. I am still hopeful of sorting this out, I am going for a sight test next week so perhaps the lens prescription is wrong, but I am not sure I will be going for her suggestion that I could always stick with the contact lenses and then have glasses for distance. One or the other please, not both!  Watch this fuzzy space!

One of the first blogs I came across when I first started this game, was Emergiblog by Kim who works in an ER Department in San Francisco and who writes with real eloquence and passion about her topic. We started blogging around the same time, and have watched each others progress through the months. She has been kind enough to compliment me on my new blog, and hers too has changed and evolved over its life so that it is well renowned in the nursing / medical blogsphere.

One of the great features on Emergiblog is:

Which reviews some of the best nursing and other health related blog posts of the last couple of weeks. Take a look there and see some of the wonderful work that people are producing; it restores my pride in all things nursing and health care! I have a post there myself, but don’t let that stop you. Keep up the good work Kim!

The proposed new structure for Governance / Education came out today, and boy has the political acting out begun! It is a structure designed by a single person for consultation by many, it is definitely going to change to a greater or lesser degree, because there are some glaringly obvious (to me and others) omissions. A few people however are pretty worried about where this puts them and who they might have to compete with for the job they might want.

Meanwhile the work goes on, the lack of funding from the government / Strategic Health Authority continues and so I spend money on educating and developing people with fresh air. At present I am adding to the financial deficit and yet this is completely unnecessary. I have a plan for the development of the workforce this year, I have pretty much costed  out and with an idea of my budget I could do great things. Going shopping without knowing either how much money you have or a list of your needs always results in spending more money, and I reckon that is what will happen. Still the NHS is a mad place right now, so I guess I shouldn’t be surprised!

When I googled coaching this was one of the pictures on offer, and actually I like it a lot. I like the idea of the orange fish coaching all the green ones, perhaps they are going to be doing the equivalent of the fish Olympics! Any way it is not that kind of coaching that I am  half way through learning but the type that you have in relation to  your job. This is a course which I have organised for our local HR departments, as they are at the front line when it comes to helping NHS staff who face the need to make changes to what they do and who may be made redundant. Redundancy is still on the cards, though I suspect will be less of an option than it was a few months ago. Now the emphasis is on saving money and on redesigning services to better meet the needs of the future. This will mean developing a more acute business sense and the skills that go with it.

I decided to gatecrash HR’s party on this and took a couple of other ex clinicians with us, because I think we are also well placed to help people with re-evaluating their careers and reviewing their skills. When I was working as a nurse, I was unaware of my potential skills in other areas of the NHS, but actually I had plenty of them, it is only over the last few years though that I have had the chance to develop them. It is great if as a nurse you want to remain at the bedside, but if you don’t or can’t (we have some nurses who have back problems severe enough to end their careers in the near future) then we need to keep these people in the health economy. Like it or not there are other jobs that need to be done outside of the bedside and I for one would rather be using the skills of those who know the system for those roles.

One thing my Masters course is teaching me, is the importance of self awareness, as I see it, if you don’t know yourself and your skills then how will you promote them and sell them to others. To a certain extent, career coaching is about helping people to do just this. It is more than preparing a CV and going for an interview, but is about looking at all of the evidence and working out as much as you can, where your competencies and skills lie and then making sure that you apply for the right job, or indeed develop yourself in the right way within the same one. This is interesting work, and something I am already dabbling in, hopefully now I will get the opportunity to develop my abilities in this way pretty soon.

I guess that many people might think that nurses, therapists and others working for an NHS organisation have little ongoing learning to do. They would be wrong. Our basic training teaches us a lot of things, but that learning then needs to continue for as long as they are working for us. First of all they need the statutory and mandatory training which addresses all those health, risk and safety issues that we need to be reminded of periodically. Things like fire training, moving and handling, infection control, record keeping, that kind of thing and then there are the skills that are directly related to peoples jobs. The theory of these can be taught in a class room, but most of the learning goes on within the work place, learning from each other, learning from doing; experiential learning.

I guess this will be where the myth of the 5 day course to teach someone to say deal with minor illnesses comes from. There are such courses available, but in order do embark on such a thing, you already need to have a reasonable level of knowledge and skill and you need to be working in an environment that you can continue to learn. It is the same as something like a leg ulcer course, you might do the  academic learning one day a week for 3 months but the learning would continue within the work place as you apply that knowledge into practice with supervision from other nurses who already have that skill.

Then there are other things that need to be learned, skills and competencies to be developed, for example how to be a manager, how to lead others. The NHS is incredibly hierachical, and structured around particular systems and processes. For example as a district nurse you might be in charge of half a dozen or more other people, nurses and health care assistants. You will need to take part in interviewing for new positions, you will need to carry out regular meetings with staff and their appraisals. You will be expected to supervise their work, and don’t forget that you are not working in a ward so cannot see their practice without putting yourself out and doing a joint visit with them or by talking to them about what they have been doing. People don’t necessarily instinctively know how to do these things any more than they know how to take out some ones sutures the first time they do that.

Everyone also needs the time to discuss issues that have happened in their practice, to reflect and look at how they would do them in the future. Many people do this any way, I know that sitting in a traffic jam on the way home (an only too common occurrence) is a good time for me to reflect. But sometimes, people need a place where they can be encouraged to do just that, to compare their way of doing things with that of others, to learn from others.

In primary care we are being expected to change the way we work big time. We have had a vacancy freeze for a year due to the financial state we are in. OK so there are complex reasons why the trust is in this mess, but we have to play our part in managing it. It has made us ask whether we in fact needed all of the staff working in the way they were or if in fact we could work smarter, more efficiently? I have recently asked one of my team to do different things to take on a new role, and have had to ask her colleague to take on her work. It turns out that she has been able to absorb the work by working more efficiently, and she has admitted that perhaps this has been a good thing. This is not to say I am supporting the wholesale rationalisation of staffing in the NHS, but what I am saying is that we need to look at what we are doing, make sure we are doing it the best way for both ourselves and for our patients and that we need to continue to learn while we do it.

Thirteen things we have to look forward to now it is October!   It might have been pretty mild here today, and I have walked the streets of  London in a short sleeved tee shirt, but it is October and we have to face facts:

1. It is dark when I wake at 6.30 and only just getting light at 7.30, and in a couple of weeks we will be putting the clocks back. We are getting shorter days.
2. The trees are changing colour, and during the next month or so they will be really beautiful. I hope to take a few walks during that time.
3. Eventually though the leaves will fall, and we will be into that period of time when many trees look bare and bleak.
4. I noticed some very nice Christmas decorations in John Lewis today, I don’t want to admit it but Christmas is a fun time and something to look forward to even if it starts way too early in the shops.
5. Of course, there will be Christmas shopping to be done, and it is likely that hubby and I will perform this task alongside everyone else. This is not so pleasant, though the act of shopping itself makes you feel kind of Christmassy. Also, I have no credit cards any longer and I will be buying presents with my own money, not on credit!
6. Sunny winter days are really great, there is nothing better than taking a walk on a cold bright sunday morning. I look forward to this, and then to the hot drink taken when we get home.
7. It is only a week or so till half term, and I am having 4 days off. I am hoping to take teen son and his cousins out for the day. The weather at the time will decide the venue.
8. We have the heating on now, and it is nice to come home to a lovely warm house when it is cold outside.
9. We can start to eat winter food, I particularly like casseroles and stews, also jacket potatoes and winter vegetables.
10. There are no more competitive England matches until March and as they seem to be playing pretty rubbish football, that is a good thing.
11. Planning next years holiday. Teen son is very keen to go to Rome next year, it seems a good place to go in the spring to give him some light relief from GCSE work.
12. Rome will be a long weekend, so there will be a summer holiday to plan. My mum has a friend with an appartment in Nice, we are hopeful of a trip there!
13. Jumpers, coats, layers upon layers. On one day we will need loads of clothes as it will be freezing, then the next it will be mild. We will be too hot in our layers and will need to adjust clothes and central heating accordingly. This is the fun of living in the UK!

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Bizarrely enough in my opinion, last nights Elvis was played by the same guy who a few months ago was Danny from Grease. Not sure he looks like either, but he was pretty good in terms of the Elvis voice. There is nothing like a spot of live music over your pasta and pizza, and every one had a great time. Even teen son said it was better than some live acts he has seen, and that is a compliment if ever there was one.

Tonight was another disappointing one for England fans, as we lost in a Euro qualifier to Croatia. In my opinion, and I am no expert they shouldn’t be changing their formation like that, and they seemed not to be able to kick the ball in the right direction. Come back David Beckham!!