My last post on this blog prompted a couple of responses that have given me cause to think about the way that what we say and write comes across to others. There is something very different about the way we say things to each other in person or over the phone where we are able to change the tone and volume of our voice, and perhaps even smile which delivers the message in the way we intend. In an email or in a comment on a blog things can be very different, particularly when we fire something off in anger or distress. Emails can cause particular offense if people are  not careful with the way they come across, for example some people dispense with any niceties like writing dear so and so and instead launch straight in. This I would suggest can cause the directness bordering on curt particularly if the person then begins to have a bit of a rant about something they perceive you or someone else has done. Experience has taught me that emails can be very useful, but also quite a damaging tool in terms of relationships between colleagues, and sometime they can be used to say things we would never say face to face.

Equally people sometimes use the comments section of a blog to dispatch the kind of words that they perhaps wouldn’t dare to utter if forced a) to reveal their identity and b) to see the expression on the person they launched it at when it is read. I have been extremely lucky, my relatively low readership is mainly comprised of sensible people who think before they write, but you only have to read a small proportion of what is published in the blogsphere  to see examples of comments posted with the most amazing vitriol. I wouldn’t go as far as to say that we all have to adhere to the ‘if you haven’t got something nice to say, then don’t say it at all’ line, but I think it might be a good idea to think about how you would feel if it were directed to you and face to face.

One of my greatest challenges over the last year has been to come to terms with the fact that for a long time I have been spending far more than I earn. Hubby’s salary fluctuates due to overtime (or lack of it) but we have tended to think it is our right to continue to spend what we haven’t earned and all will be well with the world. Well about a year ago, I realised that all wasn’t well and if I wasn’t careful something very nasty could happen. Since then I have cut up all credit cards and been in dispute with various companies over the amount I can pay back in any single month. For a while that meant dozens of phone calls, some of them threatening every day from people in various call centres around the world, but thankfully arrangements have been made with all of those companies and all money will eventually be paid back. In fact my debt has already fallen by £8000, quite an achievement even if I do say so myself.

When you get into this kind of position, the banks and their charging policies really don’t make life easier for you. I have never expected to be able to take the bank’s money for nothing, but at times the charges caused me to go further into debt, resulting in a kind of downward spiral of borrowing, charges, more borrowing etc. A number of websites are now devoted to advising on money issues, including the reclaiming of bank charges and thousands of people in this country are reclaiming those charges from their banks. Yesterday I scored a victory against a multinational bank and am to receive back nearly £1800 in bank charges taken in the last 6 years. They do not admit liability and continue to say they are right, but will give me the money anyway. I could get more by taking them to court but actually I think I’ll call it quits.

My attitude to banks and the services they provide has changed significantly over the last year. They do not get you to pay off your overdraft with a loan as an act of charity, and they do not then encourage you to build up a further overdraft as another kind act. They are making money out of this process and whats more, the people who have more money and never go overdrawn are benefiting from this, because my charges subsidise this process. No one wants to give up ‘free’ banking, but I would rather pay a small monthly charge for using the service than pay £150 in one month for going overdrawn when it is their charges for the previous month that caused the problem in the first place.

I should use all of the money to pay off more debt, but this will make the difference between a family holiday and a week spent looking out of my window at my own garden. Therefore we are off to France for a week in July, thanks to the bank and the refund of my own money!

On our trip on Wednesday we were shown this video as an illustration of what it has been like working for their PCT over the last 6 months, and boy does it ring true!!

7 weeks into my new job, I am able to look back on the whole Commissioning a Patient led NHS / PCT reorganisation process with more clarity. No one expected that it would be easy to bring together a diverse group of PCTs into just 2 (though it feels like one as there is one management structure), but then again no one expected it would be quite like it was. Basic change management theory tells you that communication is the key to such a process, and that is just the area where we were let down and to a certain extent still are. The other problem I would suggest is that the top management team, once it was formed, failed to have any kind of vision about what the new organisation would be, save one that saved as much money as possible, and in addition failed to share any kind of vision that they might have had. Even the most committed employees cannot ‘carry on regardless’ as our outgoing chief executive once advised, if they don’t know what the purpose is. Productivity (if patient care and health care management can be measured in that way) must have fallen to the lowest possible point and is only just beginning to recover. Clarity of purpose is just emerging and people are beginning to refocus on what needs to be done, and at long last some services can recruit much needed clinical staff. People have realised that the money we spend is public money, they have realised that inefficiency and ineffectiveness cannot be tolerated, but of course waste still goes on and no doubt it will continue for some time. I am sadly not convinced that all the best people got all the best jobs, but we can only hope that at some time in the future good sense will prevail and greater efficiency will follow, but then I have found some rose coloured spectacles with my new job!

This post is intended to give myself a good talking to. The end of my MSc in Strategic Leadership is in sight, and I am currently busy interviewing people as part of the data collection process. But am I working as hard as I can to write up the literature review, methodology and methods? No I am not? What am I doing instead? Well anything but working on my dissertation. You would imagine that my house would be spotless in that case wouldn’t you? Well I don’t appear to have been scrubbing floors or dusting the corners, so I haven’t suddenly become house proud. I have done quite a bit of weeding my garden as we have been having some very nice weather lately and I have also been out walking through the local countryside. Other than that, I am ashamed to say I don’t really have an excuse for my poor work rate. I have written about 2000 words of 20000 and if I am going to have anything half decent to present in June then I really must get on with it. Each time I decide to do a bit of blogging instead of writing or reading then I will do well to look at this post and remind myself to get on with it!

Yesterday I went off with a couple of colleagues to look around what was described as an integrated emergency / urgent care facility run jointly between the acute and primary care trust. For patients, and indeed for the visitor it all looks very nice, and people are getting really very good care and on the ground the nurses and doctors, who work for both sectors but work together are doing this in a pretty much seamless looking way. Underneath though there are still problems. For example the PCT still gets charged for the patients attendance, even though they could see a nurse employed by the PCT. Payment by results could end up being the biggest wedge between acute and primary care, after all why wouldn’t the acute trust want to continue to see patients if they are getting paid for each person who walks through their doors. In our own area the barrier to developing any kind of integrated facility is the relationship between the two sectors and the ensuing arguments are likely to have an effect ultimately on the care a patient receives. It was amazing to see GPs who work for the out of hours service working in the A&E environment and actually seeing patients who walk in to the urgent care facility, helping with the education of the nurses there particularly in the area of minor illness and also learning more about the treatment of minor injury in the process. I just hope the different cultures of primary care and secondary care can come together in the longer term or else this could end up being another one of those expensive projects that is begun and never carried through to its full outcomes. One of my main concerns with this whole thing though is the continued use of management / business consultants. I know it is easier to hand a project to a person or group of people to see through, but can you tell me why a) we don’t have the expertise in house, or if we don’t why we can’t create it, because this is a massive and surely unnecessary cost to the NHS!

People still do a double take when I tell them that I am now working in Children’s Commissioning. This is the third time my career has taken an unexpected turn, but this change I guess is not what I or others might have expected. There is an expectation, even now, in the 21st century that you should stay in the same kind of job for pretty much ever and that if you change to something completely different then you must be in some way mad. Perhaps I am but I am not sorry that I have made this change.

The best way to learn about the way things are run is to go out and see them for yourself, and yesterday I spent much of the day visiting the women’s and children’s services of one of our local trusts. If they find my lack of experience in this area strange then they certainly aren’t saying so, and I am keen to learn and to find out the issues they face. I was struck by the committment of all of the staff from the senior sisters to the people cleaning the floor to the work they are doing. I was struck also by the way the managers of the services have had to make changes to those services without any additional funding and how much learning and development goes on despite the shortages of staff. I was struck by the team working that goes on, by the way people from all disciplines work together for the good of mothers, babies and children. Ok so I was a visitor, people should make you welcome, but the way they speak to each other, the smiles, the atmosphere can’t be faked.

The important thing I have learnt about commissioning so far, particularly women’s and children’s commissioning, is that it is a job that cannot be done in an office, it involves interacting with real people doing real work. It involves working through issues affecting patients and their families and if you are a manager working in the health service today you are wise to take note of that.

No me either! I have held a patients hand, but then tell me what is wrong with that? There seems to be a perception that specialist nurses, particularly perhaps those looking after people with lung cancer do such a thing. I guess this would be because the perception is that they have no particularly useful role in patient care seeing as they usually don’t actually provide physical care. At the same time the implication is that the employment of such a nurse financially prevents the use of particular expensive drugs. I have been a specialist nurse, but not with patients with lung cancer. Indeed I made a decision relatively early on in my nursing career that I didn’t want to specialise in the care of people with cancer, and can’t imagine concentrating on lung cancer. I did share an office with the hospital’s lung cancer nurse though and she didn’t pat peoples hands though she did spend lots of time with individual patients talking through treatment options or lack of them and generally being there to listen and advise. She often also was there to pick up the pieces left my busy medical staff breezing in and out of a situation without taking the time to check that the patient understood the message that had been given.

There is a feeling, I would suspect, that if you don’t administer medication, don’t wash people or take them to the toilet then as a nurse you have nothing useful to give. Well that has not been my experience of my colleagues who have this kind of role or of the way they have been accepted by their patients. The best services are offered using a team approach where everyone has their part to play and where the patient is central to what is provided.

Today I heard some worrying stories about a local GP, but I wouldn’t take that to mean that all GPs have an over inflated idea of their own knowledge, skills and abilities any more than it can be generalised that this is the case of your average nurse. I have been patronised by plenty of GPs in my time, perhaps almost patted on the head, but I have never to my knowledge patted a patient’s hand.

I think one of the most noticeable changes in healthcare over the years has been the development of the culture of blame. Becoming ill is now something we have caused ourselves by taking the wrong substance (food, alcohol, tobacco, drugs) or else it is our environment. If something goes wrong in healthcare everyone seems to want to blame someone else. The nurse didn’t wash her hands properly, she didn’t have the appropriate knowledge, she was getting above her station trying to be a mini doctor. The doctors themselves cannot be without blame, they are paid too much, don’t work hard enough, aren’t keeping up to date, aren’t trained well enough any more. Then of course there is the government, responsible for our ill health, the fact that we can’t get hold of the drugs or other treatments we think we should have. They are the cause of targets and strange ideas for so called reform where nurses take on the work of doctors and doctors become health care managers which of course gets me onto the most blameworthy group. The manager is of course to blame for everything that is wrong with the health service today. Overpaid, under skilled, over educated with management courses and of course just plain useless.

Over the weekend I took a break from writing on my blog, but I did read other blog posts. To be honest some of the medical blogs I have read are beginning to depress me, and the reason for this is because there is an overwhelming feeling that all is not well with the world and the reason for that is someone or something else.  Well as far as I can see it is time to take control, time to be proactive, time to stop this blame game, time for solutions not winging, time for proper debate not some of the ping pong like oneupmanship discussion that goes on in some areas of the blogsphere.

It might shock some people to know that there is some very good healthcare going on in this country, and that it is quite possible for a nurse to provide nursing care, know something of the anatomy and disease process of her patient as well as deliver care to a high standard. It is possible for doctors to learn something from nurses, but if either of them tell a patient something that is blatantly not right then the other has a responsibility to let them know that is the case. It is possible for a GP to be willing to take part in the redesign of PCT services, it is possible for managers to know what they are talking about and it is possible that not all of them are being over paid. It is possible that government have got pretty much everything they have done since 1997 wrong, and therefore every member of the labour party need to be called unpleasant names, but I somehow think not.

Lets stop running each other down, lets stop trying to get one up on each other, after all we don’t actually do this in the course of our daily work (well I try not to). Lets start to work out the answers not just winge about the problem or am I just being a naive nurse turned manager who has got above herself?

Sad as it may seem I do not have 50 or so posts already physically written or carefully cataloged in my brain ready for use, but have to be in some way inspired. This may be through particular incidents which I want to write about or trigger memories of something else that has happened that is perhaps in some way linked, or it may come through reading other people’s blogs and feeling the need to write something on that or a similar topic.  I often go to one of my regular reads and then move through some of their links, and some of theirs and so on, I know I should get a life (actually I have one, but this is a good avoidance tactic for real life). This morning then I found my way through Kim’s Emergiblog to  Nicole’s Blog Moon is Chasing  Me, to find something which I consider quite disturbing. Nicole has been writing about her experiences as a student nurse, she is new to nursing and is encountering new patient experiences, finding out about some of the challenges and of course juggling the theoretical work and dreaded exams. As a nurse of many years experience I love to read about these kinds of experiences, I like to hear the enthusiasm coming out, I love to see how people grow and develop and am happy to offer support when things aren’t going quite so well.

What kind of nurse then would, following reading the blog of a student nurse, send off an email to that person telling them that their idealistic view of nursing is fatally flawed and that they should move out of nursing, possibly into nuclear medicine before it is too late. Firstly it is cowardly to send this (a pretty long ramble) by email rather than posting is as a comment, but secondly why write such a thing at all when you ought to be discussing your problems with friends, family or perhaps a counselor  rather than inflicting yourself on an unsuspecting person you don’t even know.

Good on Nicole then for posting the email for us all to read, and good on her too for rising above the criticisms contained within it. To be a good nurse you need to be able to critically reflect on your practice and the practice you see around you. You need to be able to justify your actions and you need to demonstrate that you care what happens to your patients. Life can be tough, the pressure put upon nurses has never been greater, but it is great to know we have future nurses like Nicole rising to the challenge.

The latest edition of Change of Shift is up at BlissfulEntropy Erica has chosen a great bunch of nursing blog posts for this weeks edition despite being involved in opening a new hospital ED department next week!

Thirteen Things I like about summer

The weather in the UK has been pretty good over the last few weeks, and it gets you thinking about summer again after those long cold dark days of winter! 13 things then that I like about the summer!

1. Long days, I like the fact that you wake up and its light and you come home from work in the light. You feel like the evening is worth doing something with.
2. Turning off the heating, we are being over charged for our gas and electricity apparently, well British Gas and others, I will be turning it off and if it is off I won’t be paying you for it!
3. Sleeping with the windows open, It may be hot when we go to bed, and uncomfortable and sticky, but there is that lovely period of time early in the morning when the air is much fresher and you bedroom is all the better for that.
4. Going for that long walk after dinner. You don’t have to wait for the weekend, you don’t have to wrap up warm, you can just go!
5. Planning holidays for that summer break - France for us again this year. We love it and planning it all is half the fun for me.
6. Weekend BBQs with family and friends.
7. Flowers, don’t you just love all those summer flowers all around the place.
8. Less traffic on the roads as people begin their summer holidays, particularly good once school breaks up.
9. Sitting in the garden in the evening or after work sipping a lovely glass of chilled rose or perhaps a white shiraz, lovely!
10. Wearing less clothes, there is something liberating about not having to wear all of those layers.
11. Repeats on TV, ok so this could be a negative, but think of all the programmes you missed that you can catch up on.
12. Finishing that dissertation - for me this year I will be free from all of that academia from the end of June (2000 of 20000 written so far!)
13. After the end of June then I am looking forward to a sunny Sunday sitting in my garden under my umbrella sipping a lovely glass of wine reading a good novel - bliss. Plus for good measure, the football season will have finished and there is no world cup or European championships to spoil the football free interlude!

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When my son was small I was anxious, as all new parents are, that something might happen to him. At that time, the back to sleep campaign had just started and so there was much awareness raising about sudden infant or cot death. But once those first few weeks and months passed my fears subsided, and the dangers became much more avoidable in my mind, and we bought various child proof gadgets for cupboards, to put into electrical sockets and stair gates to prevent him getting up or down stairs. These were a challenge for adults too and those calling round found them difficult to negotiate!

What I didn’t realise was that my anxiety about his safety would be higher at age 16 than they were at 6 weeks or 6 months, but you can’t watch the news or pick up a paper without feeling that the world is suddenly very risky for the average teenager. Kim from Emergiblog, (and I am sure many other bloggers) has been speaking about her fears for her children in the wake of the tragedy in Virginia and here in the UK many parents have recently lost sons to a series of teenage boy gun and knife murders. My son is not black and we do not live in any of the large cities where these murders have taken place, and the risks US teenagers of being murdered within the campus of their own colleges may not be large, but as parents of teenagers and young adults we fear for our offspring.

Teenagers in general terms seem to have little fear of their own mortality, they are certainly not as risk averse as we would like them to be and we have to allow them to complete their journey into adult hood. We have to keep our own fears to ourselves, or certainly out of their earshot, while trying to get them to recognise the risks. Who ever said parent hood was easy?

Lies got poor old Pinocchio into trouble, and some would say that lies are getting HM government into trouble right now. They certainly know how to bend the truth, and what better way than through statistics. Each year an NHS staff survey is conducted (currently) by the healthcare commission of staff views and satisfaction with their lot working for English Trusts and PCTs. This years report was published at the end of March and suggests that 33% of employees suffer from work related stress, 45% thought their organisation put the welfare of patients first, 31% had suffered workplace violence or abuse and 68% of staff working in an acute trust said that they were generally satisfied with their work. Well this is all very interesting stuff, and no doubt the government will pick bits out to feed to the press, into their election speeches and the like, but what do these statistics really tell you?

Well the first thing we find out is that the response rate was 53%, not too bad for a survey, but the next thing is that 50% of PCTs weren’t included in the survey at all. In October, when the survey was conducted,  many PCTs were going through major organisational change (tell me about it!), so it was not felt that these members of staff should be subjected to filling out the survey. More like the results would have skewed the results! I wonder how many people in my own organisation were happy in their work, with their employer in October, I wonder how many of those working for particularly cash strapped PCTs felt that the patient was the most important priority? In October the new PCTs were formed, staff were feeling uncertain and were beginning to leave in their droves, from both clinical and non clinical roles. Some services have been nearly wiped out through what might be described as natural wastage, people leaving and their posts being frozen and although some recruitment has begun staffing will never return to the levels it was before. I am not arguing about the rights and wrongs of replacing like for like here, but the effect such changes have on those left behind, and let me tell you they wouldn’t have been kind to their employer in any kind of staff survey. It would have been nice to have been asked though!

The RCN said yesterday (just in time for their annual congress which starts today) that 13,000 NHS jobs have so far been lost. The government of course deny this, saying that the NHS is in the best state it has ever been and that there have been just a few compulsory redundancies, well it is ok for people to leave their posts and not be replaced then is it? There are also claims that these posts are often not front line, and instead are ‘just’ unnecessary pen pushers. Well many of the posts are clinical, and this is affecting services, and just because people work in an office doesn’t necessarily make them useless on not required.

The way that the NHS has treated people over the last 18 months has probably caused the worst morale I have ever seen in my 26+ years of service. I place responsibility for this squarely at the feet of Patricia Hewitt and her team at the Department of Health and at Tony Blair, because in my book, the buck stops as close to the top as possible.  They were responsible for the changes that took place in the NHS in the late 90s and into the new millennium, they set the targets which the trusts had to meet, and because of that the trusts recruited former clinicians and others into administrative jobs. In my own area financial problems can be traced back at least 10 years, and to begin with these problems were solved by borrowing and more than likely playing a game of cat and mouse which meant no one realised the true extent of the problems. Just as I had to face my own financial issues last year, though luckily we are talking very small amounts in comparison, so the local trusts are now addressing theirs. It is painful, we expect that, but it is the lack of respect for people who have given years of service that grates on me most. 2 of my colleagues are now working their compulsary redundancy notice, these are former nurses, who have been respected managers and who are still doing work not done by others. They have no permanent jobs, and no job title. They have been told that it is more than likely that at some point before 30th June they will be offered a job, as the trust cannot afford to pay the redundancy they deserve. One of these colleagues is finding this position very difficult to cope with and her health has begun to suffer. Is this any way to treat your employee, to show that you care, especially if you are an organisation that is meant to be one offering care to patients? Next time you dismiss those losing their jobs as ‘pen pushers’ then give a thought to this, those pen pushers are human beings with real feelings, a real mortgage and real family to provide for. Being a statistic is no comfort to anyone!

The weather here in the UK is unnaturally warm for April, but I am not really complaining. It gives me the opportunity to get outside do some gardening and go for some walks through the every decreasing English countryside. These daffodils  are in my own garden, and I think it is time I did some weeding between them as there is more grass on the flowerbed currently than there is on the lawn! I wouldn’t say we are very good gardeners, we like the garden to look good, but don’t really put in the time that is necessary to make our garden one of those perfect specimens you see on your travels, in magazines and on TV. In my ideal world weeds would be something you remove the once a year and then they would not return until the following year. Sadly reality is not like that the weeds do return and of course you need to give your garden regular attention.

One of my former team members asked me this week how the PCT can improve uptake of appraisal. Apparently people know that appraisal is mandatory but they just don’t do it, and he needs to work out what the learning and development team can do about this. Should they do some awareness raising? Well in my opinion that might be a recipe for disaster at this point in time, people who are struggling with unfilled vacancies and no the reality of little available finance for training will be a little angry if told they need to appraise more staff. In my opinion you need to look more closely as the root of appraisal, and its purpose, which is to make sure that organisational objectives are cascaded into the work of the individual workers. The trouble is that at the moment you would be hard pushed to know what the organisation’s objectives are, save of course the need to save money and regain financial balance, that might however be considered more of a pipe dream than an objective, but that’s another issue.

The other thing that needs to happen is that people need to understand that appraisal is not about the courses you want to go on this year, but about how you will help the organisation meet its objectives. My advice then, and I am glad it has nothing to do with me any longer, was to say that he should suggest that someone tell the top management team to identify their objectives and share with the rest of us what they are. Now that might form part of a very interesting newsletter! Mean time, I’ll get on with weeding between my daffodils!

As a UK nurse I am registered with the Nursing and Midwifery Council (NMC), and of course pay for the privilege. The purpose of the nursing regulator is to protect the public and in order to do that, the NMC guides us in what is appropriate behaviour and advises us in how to interpret the rules and regulations that govern us. In a kind of good guy / bad guy way, they send us a quarterly news letter called the NMC news, you could describe this as free, though of course it isn’t as we pay for it indirectly through our regulation fees. Sometimes NMC news is in stick hitting mode, with features on what has appeared at the misconduct committee and what is new in the rules on say giving medication. This time the stick hitting bit is about the injection of botox and a nurses role in this and also tells us about the new code of conduct due to be issued next year. But there is definitely a softer edge to this issue (not yet available on line, but click here for previous issues), and instead has features about nurses and midwives. The one that really caught my eye though was about Kathleen Burden who at 87 is currently the oldest person on the register. When I joined the nursing profession, the register was a ‘dead’ one, meaning that you were not required to re-register or prove your competence to practice and so could die and still be a registered nurse. Kathleen Burden became a nurse at the beginning of the second world war, and worked as a nurse and midwife around the world before settling in the UK as an orthopaedic nurse. She continued to practice, and to update her knowledge and skills up until last year, working part time in her son’s nursing home.

Reading about Kathleen had a couple of effects on me, firstly it made me feel a bit embarrassed about having given up bedside nursing at the age of 39, mind you if I could practice in my 80’s I can always go back to it at this rate. But also I was slightly in awe of the thought of such a fit elderly lady wanting to continue to care for people, a lady who continues to understand the origins of nursing and has practiced her trade accordingly. She is critical of the current generation of nurses who she considers less dedicated to their work. I believe that we are living in a different world to the one Kathleen looks at with such fondness, the patients expect more from us, we expect more from our lives and I am not really talking about money but about the conditions within which we work and also live. We question more, patients and their carers question us more and we have to justify our actions not just to our regulator but to our employer and to each others in a way we never did before. Kathleen Burden will leave the nursing register this year as she has finally retired and will not re-register later this year, I think our profession may well be slightly poorer for that.