When is a nurse not a nurse?

12 days ago Dylan went in for the biggest operation of his young life. He was very brave and went off with his nurse without a backward glance. The operation was a success and as it was a day case, he was discharged home, complete with his post-operative painkillers, later the same day. Last Friday he had his out-patient appointment. I got a phone call early on the morning to say that his nurse had rung in sick and his appointment would have to be rearranged for another day. Dylan was naturally disappointed, and I was cross at the inconvenience. However, it couldn’t be helped. It seems the world of veterinary nursing might be just as fraught with sickness as it is in human health care.

Of course, Dylan’s well-being wasn’t compromised by the cancellation. He is a young, healthy dog, and he was after all being looked after by myself, a qualified nurse. In the UK anyone can call themselves a nurse. However, the title ‘registered nurse’ is a protected one, although in an everyday sort of way, it’s not a common term. The more familiar term, ‘nurse’ is not protected by a regulator or by law. It’s important as a protected title represents a contract between the State and a profession – so that the public can be assured that anyone using that protected tile has been appropriately educated, properly trained and regulated. These days, I am no longer registered as a nurse with the regulatory body, the Nursing and Midwifery Council, so I cannot practise as a qualified nurse any more. However, that knowledge and experience of being a nurse is still there. 

So the slightly (?) existentialist question is ‘when is a nurse not a nurse?’ The word ‘nurse’ has become embedded over hundreds of years in society’s collective psyche. It has many meanings. Have I stopped being a nurse because I have let my registration lapse?  I don’t think so. However, I don’t think I would want to work in clinical practice any more, although I do miss the teaching. Most of my remaining PhD students are nurses and their studies focus on the everyday problems of practice, both here in the UK, as well as overseas. And clinical practice can be quite a fraught place these days. The demand for health care continues to grow exponentially, and the how and where services are being provided gives rise to a different set of challenges for nurses than possibly the ones I faced in my day.

Perhaps the more prosaic question ought to be ‘where have all the nurses gone?’. We know that many older, more experienced nurses are leaving the profession in greater numbers than ever before. Uncertainty over Brexit and the removal of the student bursary have had a huge impact on the supply of registered nurses into the NHS. Today there are over 100,000 vacancies across the NHS. The projected gap between the number of staff needed and those available is likely to rise to 250,000 by 2030, if nothing changes. Of the 100,000 current NHS vacancies, over 41,000 are nursing vacancies.

Dealing with these international challenges (yes, it’s not just the UK that’s affected) is a problem of King Canute proportions. But, there is someone waiting in the wings who might have some answers. Cue RCN Anne-Marie Rafferty. Now I have only had one remotely intimate conversation with Anne-Marie, and that was over breakfast at a Council of Deans meeting many years ago. I don’t think she chose to sit with me, as much as the seat at my table was the only spare seat in the restaurant. It was a breakfast conversation that I will never forget. She had (has) a passion for the promotion of the nursing profession that I’m sure others saw in electing her as President of the RCN in 2018. 

It was Anne-Marie, along with other colleagues who undertook some research into the connections between nursing skill mix, mortality, patient satisfaction and the quality of care – see here. It was an interesting piece of research, undertaken before the new role of Nursing Associates had become embedded in the UK health care system. There were limitations on the research process which need to be taken into considerations when considering the findings, but essentially there was a clear connection between enhanced levels of patient satisfaction, the quality of care, the level of mortality, and the numbers of registered nurses on a shift at any one time.  

Now I don’t know what solutions Anne-Marie might have up her sleeve in terms of solving the nursing shortage, but maybe she could look at what’s happening in the world of veterinary nurses. Back in 2015 the Royal College of Veterinary Surgeons (RCVS) recognised that they were losing too many veterinary nurses due to poor pay, stress, and the nurses not feeling valued. Before anyone shouts at me for saying there are only 12,500 veterinary nurses compared to the 287,000 whole time equivalent registered nurses (and Health Visitors) working in the NHS across England, I know I’m not comparing apples with pears. The point is they did something about these issues and have turned the situation around. 

Whilst there is a perceived shortage of vets in the UK (another victim of Brexit), veterinary nursing continues to be a vibrant professional choice. As I was sitting waiting for Dylan after his operation, I looked at a Blue Cross advertisement aimed at attracting potential veterinary nurses. It was interesting in its similarities to registered nurse recruitment advertisements: 

‘working as a veterinary nurse is hard work, but it’s also extremely rewarding’ 

‘you need to have a strong stomach to cope with unpleasant sights and smells and the stamina to stand on your feet all day’ 

‘animals aren’t sick from 9-5, so nursing jobs involve evening, weekend and Christmas work’ 

‘it’s worth remembering that pets come with owners, so you need to be confident dealing with people too’.

There are no easy answers to the nursing workforce shortage, but there is much more we might do to increase the numbers of those wanting to join the profession.  In answer to my earlier question – when is a nurse not a nurse, I guess the answer is when they aren’t any registered nurses left.

The stubbornness of mules, Mothers and men

I once bought a soft toy (a donkey) from a charity shop; a gift for my dog to play with. When I got it home, I found that if you squeezed its belly, it would say ‘I’m as stubborn as a mule’. Needless to say, the dog was given something else to play with and I kept the soft toy as a way of dealing with the stubbornness of my children, and latterly, my grandchildren. I don’t know where the simile comes from (possibly from the 1800s) but it reflects the so-called stubbornness of mules who over history have gained a reputation for obstinacy. Now in the past I have kept a donkey, and apart from her raucous braying ‘hee-haw’ she was a wonderfully compliant and willing animal. I don’t know about mules, but I wonder if their reputation for stubbornness is justified. 

Stubbornness in humans is slightly different. Not all folk are stubborn. We don’t really know the causes of stubbornness, but studies show that like other traits, it might be inherited, or acquired through social upbringing, whereas other studies indicate that stubbornness is due to a lack of dopamine. Dopamine is the neurotransmitter that is responsible for the feeling of joy, pleasure, and fun. It also helps in learning. 

Over my lifetime, a number of people have called me stubborn. Often this has not been seen as a virtuous quality, quite the opposite. I think I inherited this trait from my Mother, who whilst being generous, loving and caring to all those she meets, is the most stubborn person I know when it comes to looking after her own health. Apart from emergency situations, she is most reluctant to seek medical help when needed. She has a wonderful range of excuses at her disposal and uses them all on a regular basis – stoicism (I just have to put up with it); it’s an age thing; I can’t get an appointment; and there is nothing they can do anyway. 

Interestingly, these are like the excuses men use in avoiding seeking medical help. Many studies have been undertaken that show that men are conditioned by society to be strong, brave and to never seek help. There is a wealth of studies that show the link between masculinity and health issues in men. Like my Mother, the difficulty in getting an appointment can be enough of an excuse not to go to their GP. Even when men do go to see their doctor, they tend to be less honest about their health problems then women. Where this is the case they are less likely to get the right treatment and the complications that might bring. Its no wonder that men can expect to die approximately five years sooner than women.

Now dear reader, it is ‘True Confession’ time. I’m a man, and a couple of weeks ago I tripped and hit a high kerb with my right shin. As it was on a busy street, I immediately felt embarrassed and despite being in great pain, got up and limped away. I didn’t look at my wound for the rest of the day, although I did think I could feel it bleeding. When I did look later, my leg was a mess. A bit like the proverbial cobbler and his child’s shoes, I had no dressings or plasters in the house and had to fashion a dressing out of tissues and Sellotape. Over the next 10 days I administered self-care. I tried every dressing possible, including manuka honey dressings. However, my leg remained painful, swollen, and looked to be infected.  I walk every day, usually anything from 30 – 50 miles a week. However, over the 10 days it became harder and harder to walk and driving my car just left me exhausted. I was also very grumpy. 

Despite J insisting from the start (and on a daily basis) that I go and see my GP, I soldiered on. Apart from the risk of sepsis, I knew my injury wasn’t life threatening and in time my self-care would bring about a restoration of health. However, the infection grew worse, the swelling in my leg made it impossible to wear anything but shorts, and my ability to even achieve my 10,000 steps a day diminished. So, when I woke up one morning feeling totally exhausted with the pain and lack of mobility, I knew I had to get some help. 

The thought of spending ‘goodness knows how long’ in my local A&E Department, who earlier this year only achieved 40.1% of patients being seen within four hours, and who continue to be one of the worst performers for emergency care in the NHS did not fill me with deep joy. Such a dismal track record is not entirely the hospital’s fault. They are one of the busiest A&E departments in England and the demand for treatment has grown phenomenally. The alternative was an Urgent Care Centre with a walk-in service available between 8am and 8pm every day, 365 days a year, and it was located just five minutes’ drive from my house. It was a fabulous place. There was a pharmacy, dentist, x-ray department, therapy facilities and even the ubiquitous consultants’ car park.

I got there at 8.15am and there were already about 20 people waiting to be seen. Mainly men, and, mainly middle-aged men. The reception area was akin to a 5-star hotel, and the welcome just as good. I settled down to read my Kindle, but only got a few pages into my book when I was called. The examination was thorough and carefully carried out. The doctor’s approach was warm and caring. She said I had a fracture to my tibia, and the infection had really got a hold. So, antibiotics were prescribed, as was a RICE regime for the next 4-6 weeks (R rest, I ice, C compression, E elevation). She suggested coming back for a confirmatory x-ray in a couple of weeks but felt sure if I stuck to the RICE approach, I shouldn’t have any problems healing.

As I write this, I have adhered to the treatment plan, although I have found the antibiotic therapy hard to live with. Its been difficult not walking, gardening, driving or cooking, but that same stubbornness that got in the way of me seeking help in the first place has come to the fore in sticking to what was prescribed. The result is I’m feeling much better in myself, less grumpy (to the relief of others), the pain in my leg is manageable and the infection is definitely in retreat. The bonus is that the long Easter holiday break promises to be sunshine filled and I am looking forward to sitting outside and enjoying every moment I can. 

Remarkable people, a Black Hole and Kindness

Hats off to the young computer scientist Katie Bourman, whose work helped bring us the amazing picture of a black hole last week.  She is just 29 years old. Just six years ago, she was a PhD student at the Massachusetts Institute of Technology (MIT). There she led on the creation of an algorithm that could take the masses of astronomical data collected by eight radio telescopes and produce one coherent image. The eight telescopes, located across the world, ‘acted’ as one telescope, the so-called Event Horizon Telescope. It was this telescope that brought us the picture of the black hole and opened up a whole new stream of scientific questions to be answered.  It was a truly amazing moment. In anyone’s book, Katie Bourman is a remarkable person, and she was part of a fantastic team. 

Last week, I was also privileged to meet two other remarkable people. It happened on Thursday, as I chaired a selection panel hoping to recruit a new Consultant in Acute Medicine. It was the first time I had been part of such a panel and I wasn’t sure what to expect. On my side of the table were four consultants, one of whom was the Medical Director, the Chief Executive and a representative from HR. It was a formidable interviewing panel. After we rearranged the Board Room tables and chairs to make the room look less intimidating, we started on the process of deciding who would ask what questions, and in what order. My role turned out to be almost ceremonial. I was there to chair the interview, explain what was going to happen, who would speak and when, explain how we would let the candidates know the outcome of the interview and generally try to ensure a fair and equitable process was undertaken. I was allowed one question, more of which later.  

Although we had several vacancies, there were only two candidates - a man (Tom) and a woman (Joan) - (not their real names!), both of whom were already consultants. However, one had 18 months experience as a consultant, and the other almost some 11 years. Joan was interviewed first. Now I might be getting older and everyone looks younger than they did in my day, but Joan looked amazingly young to have already developed her career in clinical practice and medical education. She was a breath of fresh air. Self-confident, assertive, knowledgeable and able to draw upon her experience in responding to the questions. 

I was surprised that there were no actual medical questions asked. It appeared that Joan’s qualifications, of which there were many, stood as a given testament to her clinical knowledge and experience. Instead the questions centred around team working, ethics, avoiding heroic interventions, health economics and managing scarce resources, improving patient flow and commitment to research and development of acute medicine. None of the questions fazed her at all. She even took on the Medical Director and challenged him over the different approach they would both adopt in dealing with a complex case. 

My question was the last one asked by the panel. I asked, ‘can you give us an example of a time when you were kind to a patient?’. There was silence. That complete, and to some, an excruciating silence. Just as I could sense the Chief Executive leaning forward to intervene, Joan started telling us of an elderly patient she had been looking after. The patient had a terminal illness and was being provided with end of life care. Each day, Joan would talk to the lady on her ward round. One day she asked whose was the cat in the picture that she kept on her bedside table. The patient told Joan it was her cat; a cat she had looked after for many years, and here in hospital she missed holding and stroking the cat. Despite protests from her Infection Control colleagues, Joan arranged for the cat to be brought in, so her patient could spend some time with her again. Soon after the lady died. 

It was the panel’s turn to be silent. But not for long. I said thank you and that her story resonated with all of us on the panel. Back in 2014, we were also providing end of life care to an elderly lady. She had kept horses all her life and had mentioned to one of the nurses how much she missed not seeing her favourite horse every day. You guessed it, the Deputy Director of Nursing arranged for the horse to be brought to the hospital and the patient to be taken outside in her bed to meet her horse. The horse clearly recognised the patient and walked up to her and nuzzled her face. The moment was captured on someone’s smartphone and the picture and the story went viral over the following 24 hours.  

Tom’s interview followed a similar path, and although his response to my kindness question was more situated in the realms of compassion, it was an equally compelling story. Both Joan and Tom, in different ways were remarkable people. Like Katie Bourman, they understood what effective team work could deliver.  All three of them brought to life the notion that often in life it’s the little things that can make the biggest difference. 

And yes, subject to the usual checks, both Tom and Joan were offered posts in the hospital.