Extraordinary times and extraordinary measures

IMG_3308The present situation regarding the coronavirus has clearly been disrupting for nursing students, especially those in their final year. All students making the transition from being a final year student to a Registered Nurse need support. But right now they will need more support than even. The current set of final year nursing students are in a unique situation and, with any luck, this will probably never be repeated.

The NMC and the RCN have both issued guidance to explain what is happening. The RCN guidance New measures for nursing students will enable more to help during COVID-19 crisis  states:

  • first-year nursing students will continue with their degree programme, with clinical placements paused for the duration of the emergency. These nursing students may volunteer or undertake paid work in a clinical setting in their spare time, while they maintain their academic study. However, volunteering or paid work will not be counted towards the practice hours and experience required to complete their pre-registration course.
  • all other nursing students, including postgraduate diploma and masters students, but excluding third-year students in their final six months of their undergraduate degree will be invited to opt-in to an arrangement where they may spend 80% of their time in clinical practice, which will be remunerated and count towards practice hours. These students will spend 20% of their time in academic study during this emergency period to ensure structured, regular contact with their approved education institution.

The NMC has issued a comprehensive set of guidance and proposals: Information for students and educators. Under emergency standards they state:

  • enable student nurses and midwives in the final six months of their programme to complete their training in appropriate placement settings
  • give educations institutions and their practice learning partners more flexibility to ensure students get appropriate support and supervision
  • enable students to use their knowledge and skills appropriately during this time of crisis to support the care of people

Please seek support when you need it if you are a student; colleagues in education and practice, please be aware of what is happening to students in your clinical areas. Above all, for the duration of these extraordinary measures, support each other.

 

Launch of the European Centre of Excellence for Research in Continuing Professional Development 26th February 2020 at the Royal College of Surgeons, Ireland (RCSI) in Dublin

STaR blog: Dr Jane Wray, Director of Research, Faculty of Health Sciences writes:

I was very excited to attend the launch of the new European Centre of Excellence for Research in Continuing Professional Development at the Royal College of Surgeons, Dublin, Ireland on 26 February. It is a real honour to be part of this exciting new venture and represent the Faculty of Health Sciences and the University of Hull.

GroupShot
The Pan European network for the European Centre of Excellence (CoE) for Continuing Professional Development (hosted by the RCSI)

This Pan European network of researchers, clinicians, regulators and professional bodies has come together with shared interest in, and passion for advancing the science of continuing professional development (CPD) through research. Ensuring that healthcare staff have opportunities to maintain, develop and update their skills is fundamental to the delivery of high quality, safe and effective care.  As healthcare professionals, we have an obligation to ensure that we practice in line with best available evidence (The Code, Nursing and Midwifery Council, 2018), and this can only be achieved by acquiring the new knowledge and skills needed to meet the future changing needs of the people we care for and support. Healthcare organisations invest in a range of CPD activities for their staff to achieve this. We do know that staff consider CPD to be important, opportunities to develop both personally and professionally help create an organisational culture that values staff learning and wellbeing, aiding retention and workforce productivity. However, despite this investment and commitment, the evidence base for CPD in terms of its impact on clinical practice and patient outcomes remains poor.

The launch of this Centre of Excellence is an important step in developing the evidence base through cross-disciplinary collaborative research activity and knowledge exchange. The Centre is the ‘brain-child’ of Professor Thomas Kearns, Executive Director, Faculty of Nursing and Midwifery (RCSI) and currently has members from over 20 countries including; Albania, Belgium, Croatia, Faroe Islands, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Lithuania, Malta, Netherlands, Portugal, Romania, Slovenia, Spain, UK, and USA.  The centre has already established three working groups that are focused on evaluating the impact of CPD, digital pedagogies for CPD and the economic impact of CPD. The centre will act as a catalyst for new ideas and guide future standards.

For more information about the centre, please contact Dr Cathy Fitzgerald, Research Fellow cathy.fitzgerald@rcsi.com

39th Annual International Nursing & Midwifery Research and Education Conference 2020 [26-27 February Royal College of Surgeons Ireland, Faculty of Nursing and Midwifery]

Jane Wray writes:

I was delighted to be able to attend the conference this year and present some more of your findings from the STaR project on “Student Reflections on the Transition to Newly Qualified Nurse”. I delivered my session to a mixed group of recently qualified nurses, clinicians and academics and it was really useful to get some further feedback on our work to date. Thanks to everyone who attended and asked questions. The importance of supporting the nursing workforce and nurturing ‘new nurses’ (not eating them!) was also highlighted earlier in the day in the keynote speeches.JW at RCSI (1)

This year the conference placed the International Year of the Nurse and Midwife 2020 at its very centre and was opened with a message from Dr Tedros Adhanom Ghebreyesus (Director General, WHO). This was followed by Ms Elizabeth Iro (Chief Nursing Officer, WHO) who delivered the keynote address ‘Nurses and Midwives Making a Difference: A Global Approach for Country Impact”. She spoke about the important role of nurses and midwives and that this year was a once in a generation opportunity to make visible the contribution to universal health and wellbeing. She asked ‘Why now?’ and answered ‘Why not?’ it was time for nurses and midwives to raise their voices and tell their stories – and to look beyond 2020 and leave a legacy for the future.

Lord Nigel Crisp (1)These messages were reinforced by Professor Rita Borg Xuereb (International Confederation of Midwives) in her keynote address “Celebrate, Demonstrate, Mobilise, Unite”. She described 2020 as a unique opportunity to collaborate and advocate for our professions and the need for investment to scale up and deliver transformative education, lifelong learning, regulation and research. The final keynote of the morning was from Lord Nigel Crisp (Co-Chair of the UK’s All Party Parliamentary Group on Global Health and Co-Chair of the Nursing Now campaign) on “Nursing Now – Lessons from the Campaign and Thoughts for the Future”. He was very clear that if you enhance the profile and status of nurses and midwives you enhance the whole team as they are at the centre of healthcare. His final comments focused on the need to leverage the momentum of 2020 and Nursing Now and create a legacy (and a big thanks to the Burdett Trust for Nursing for supporting this work).

 

 

 

 

Newly graduated nurses’ experiences with death and dying patients in medical units at patient safety hospitals in Denmark

cajuje

This is the second of two entries from Carsten Juul Jenson, a colleague from Denmark, who is undertaking a PhD in self-blame among nurses.

In my PhD thesis, I employed institutional ethnography (IE) with participant observations, interviews and analysis of political documents to inquire newly qualified nurses’ (NQN) work at death and with dying patients in medical units. NQNs who are unfamiliar working with death and dying may consider themselves as failed nurses (murderers) if patients die; death could be perceived as a mistake. In patient safety hospitals, the political goals of quality improvements are related to health, survival and hardworking productivity. Though, as I emphasize below “is isn’t your fault”, NQN cannot be found guilty of the deaths of older acute ill patients with comorbidities in the medical unit in which they work.

One NQN, Anja raises her voice: “I, am afraid of killing patients” and Martha said: “I do kill the patients”, which I present in a poetic representation with inspiration from critical feminism. It is Martha’s first week in a medical unit, which starts on the first day of Martha’s employment. I followed Martha in the morning round to check patients’ health conditions:

Ole, Christian, Hans, Christa and Andrew die.

Is he?

No, it can´t be true?

Look at Carsten who looks back at Ole.

Carsten says: “I think he is….”

I have to go in there. He isn’t breathing.

I just have to look at my notes – he is not supposed to be resuscitated

 

I have to learn it

I have to feel what his skin feels like

He´s cold, but not that cold.

His skin feels weird but not as spooky as I had imagined

 

Christian died today too

I almost cried because his daughter cried

 

Hans died on Tuesday

 

Christa died on Wednesday

 

Andrew died on Friday

 

I was able to manage the first one, but enough is enough

No, I´m not allowed to cry

Nurses don’t cry

I can’t help it – my eyes get filled with tears

I DO KILL THEM

 

Most activities in hospitals including medical rehabilitation units, health promotion, resuscitation and identification of critical illness use various “early warning” tools. The clinical guideline for these activities no longer apply if patients are incurably ill, although, as Rebecca says: “I would rather not give her the death blow,” when she must give an incurably ill woman morphine.

“It’s not your fault that you break down” – a study of self-blame in newly qualified nurses in medical units in Denmark

cajujeThis is the first of two entries from Carsten Juul Jenson, a colleague from Denmark, who is undertaking a PhD in self=blame among nurses.

In an institutional ethnography (IE) with participant observation, interviews with newly qualified nurses (NQNs) and analysis of political documents, I show that NQNs consider themselves as individually responsible for inadequate capacities in problem solving in medical units in Denmark.

However, individual self-blame varies according to gender and age: Thor’s (male), Anja’s (35 years old) and Martha’s (29 years old) emotional responses to their new role as a nurse seem less self-blaming than that of Emilie (25 years old) and Rebecca (23 years old).

Emilie has to go off sick due to physical symptoms of anxiety, as she felt personally responsible for leaving unfinished nursing tasks for her colleagues, even if she has to provide care for a patient, who has been incontinent of urine.

Rebecca reflects, “Why did I do bathroom 6 first?”, while she had helped a talkative and time-consuming patient, instead of answering a bell from a bathroom, where she unexpectedly found a patient, who has collapsed from incurable respiratory distress.

These young NQNs blame themselves even though they are working in conditions that it are above human capacity to predict and live in constant fear of harming patients fatally despite mainly working with older patients with comorbidities and acute illnesses. Anja, who explicitly expressed fear of being blamed for patients’ death, states: “You know, I went home crying, but it’s not my fault, it’s the working conditions that are unreasonable.”

The service-minded approach of new public management reforms of hospitals in Denmark stresses individualism thus these young new nurses find themselves shouldering this responsibility The young women Emilie and Rebecca appear overly responsible and conscientious in their efforts to handle nursing care for the least amount of money in medical units overcrowded with older patients

In an interview for the Danish Nurses Organization in May 2018, I raise my voice emphasizing: “It’s not your fault that you break down”. I wish to relieve the pressure of individualism. NQNs cannot be held individually responsible for discrepancies between delivering health for the least amount of money and demographic changes with an ageing population more than 80 years old, of whom 80 % are hospitalized with acute illnesses.

James Buchan writes:

We have a new government. Time to revisit an election promise, which has a direct connection to the STaR project. “50, 000 more nurses by 2024/5” was the Conservative manifesto commitment in December last year. This was immediately brokered down to 31, 000 additional “new” nurses, because part of the plan was to encourage about 19,000 existing nurses to stay on[i].

Boris Johnson had barely re-crossed the threshold at number 10 Downing Street before the new government made an announcement about changed funding modalities for student nurses in England. An annual grant of £5,000 to cover living costs is promised to all new and current undergraduate student nurses[ii]. A further £3,000 will be available for people studying hard-to-recruit disciplines, such as mental health and learning disability nursing. This new money will not cover tuition fees. Students will still be required to pay tuition fees of £9,000 a year.

Even with this “new” money, the scale of the nursing shortage in NHS England will take some solving. Recent research by the Health Foundation[iii] highlighted that that nursing remains the key area of shortage and pressure across the NHS, and that recent modest growth in nurse numbers has not kept pace with demand. NHS nursing vacancies increased to almost 44,000 in the first quarter of 2019/20, which is equivalent to 12% of the nursing workforce. To prevent nursing shortages growing further, urgent action is needed to increase the numbers of nurses in training, reduce attrition and improve retention.

In 2019 the number of applicants to nursing courses in England increased for the first time since the NHS bursary was withdrawn in 2017. The number of applicants in England had risen to 40,780, but nevertheless remained below the figure for 2017. In contrast, Scotland, where the NHS bursary has been retained and its value increased, saw a 6.7% increase in student nurses in 2019, taking the number of applicants to its highest ever level.

If the NHS is to reduce vacancies and grow the pool of qualified nurses to recruit from, the forthcoming NHS People Plan will need to set out measures that will rapidly expand the number of people starting undergraduate nursing degrees in England. Analysis by the Health Foundation shows that there are different patterns of applications and acceptances by age, branch of nursing and geography.

For example, the numbers of students starting mental health and learning disabilities nursing fell significantly between 2014 and 2018. All continuously running learning disability courses had fewer students in 2018 than in 2014. This is in contrast to children’s nursing, where around two-thirds of courses (63%) had increased in size. Fewer over-25s started nursing degrees in 2018 compared with 2016, particularly impacting learning disability and mental health courses.

Overall trends can also hide pressure points in different areas of the country. Adjusting for population size London and the South East are in the bottom three regions for the number of acceptances to study nursing and the top three for the number of vacancies per 100,000 people.

As highlighted in the work for STaR, a relatively high proportion of students who start a nursing degree do not graduate within three years – either dropping out completely or putting their studies on hold. The latest data analysed by the Health Foundation showed that attrition remains stubbornly high despite government commitments to reduce it. One in four nurses who were expected to graduate in 2018 did not do so, and the overall attrition rate was highest for learning disability courses.

There is a time lag of four years before new student nurses become productive professionals. Even if the newly promised funds attract more student nurses, there can be no quick win for the government in achieving the 31,000 target by 2024/25 just by increasing the intakes of new student nurses this year and next. It will also have to work effectively with universities and employers to then reduce attrition rates of those who have been attracted to a student nurse place. STaR is well placed to give insights and support to an evidence-based approach to reduce attrition and support successful transition into practice.

[i] Buchan J (2019) How will the Conservative election pledge of 50,000 more nurses by 2024/25 be realised? Nursing Standard, 18 December 2019 https://rcni.com/nursing-standard/opinion/expert-advice/how-will-conservative-election-pledge-of-50000-more-nurses-202425-be-realised-156321

[ii] Jones-Berry S (2019) Nursing students in England to receive £5,000 grant from next September. Nursing Standard, 18 December 2019. https://rcni.com/nursing-standard/newsroom/news/nursing-students-england-to-receive-ps5000-grant-next-september-156506

[iii] Buchan J, Gershlick B, Charlesworth A, Seccombe I (2019) Falling short: the NHS workforce challenge. Workforce profile and trends of the NHS in England. Health Foundation, London

https://www.health.org.uk/publications/reports/falling-short-the-nhs-workforce-challenge

‘Should I stay, or should I go?’ Are NQNs leaving their first post within 12 months?

Jane Wray writes:

I recently posted a comment on Twitter about the fact that several of my former students had contacted me for a reference for a new job all within the space of three weeks. All had qualified about a year ago (Oct 2018) and it prompted me to ask on Twitter “is this usual? 12 months and then move?”.IMG_6712

There were a few responses to my poll (28 in fact) with 25% indicating that they would move to a new role, 36% were staying where they were and the biggest group – 39% were ‘still deciding’. However, what was interesting was the number of people who commented on the poll and this very issue of whether they should stay or move on.  Most of the comments indicated that NQNs did leave within 12 months or so of qualifying or they were about to leave sometime soon. This was because they got promoted or a better job offer from another organisation. Some left because they were seeking a new challenge and a few (the minority) said that they had not settled in their first post or did not feel it was a supportive environment.

So yes – NQNs are leaving within the first 12 months but this appeared to be for mainly positive reasons. If you have the offer of promotion (more money!), or a job that suits you better or a different role that provides you a new challenge then why would you not move? Alongside these comments were also some from nurses who had been qualified for over 20 or even 30 years who indicated that they too had moved on within or around 12 months of qualifying. This ‘moving on’ within the first 12 months is not a new phenomenon and is something that perhaps many NQN do. Nor does it appear to be a consequence of negative circumstances and situations.

I am mindful that NQNs moving on within 12 months impacts on workforce retention and that this is currently a huge challenge for most healthcare organisations particularly in the NHS. However, some of these reasons for moving on (promotion, different job or a new challenge) might easily be provided by the organisation that the NQN is currently with – and if this was offered, would they stay or still go?

Celebrating at the National Retention Awards in London

On Tuesday 19th November the first ever celebrating nursing retention awards were held in London. Jointly hosted by the Burdett Trust for Nursing and NHS Improvement, this was an opportunity to celebrate and thank those that have been doing brilliant work around staff retention across the country. There were several formal presentations on good practice –showcasing work done by NHS Trusts with support from NHS improvement to improve staff retention. Alongside the formal presentations, there were awards for excellent retention work across several categories. My take home message was definitely “place staff at the centre of your retention work; support and value them and then you will retain them”.

IMG_6768
Jane Wray talks to Shirley Baines, Chief Executive, The Burdett Trust for Nursing celebrating at the National Retention Awards in London

Nominations (and winners) were as follows;

  • Best career planning and development offer (Warrington and Halton Hospitals NHS Foundation Trust)
  • Best retention offer to support equality, diversity and inclusion (Sherwood Forest Hospitals NHS Foundation Trust).
  • Best Support for those approaching retirement (Mid and South Essex University Hospitals Group)
  • Best Flexible working offer to support work-life balance (Lancashire and South Cumbria NHS)
  • Best Staff Engagement and Communications offer (Northumbria Healthcare NHS Foundation Trust)
  • Best use of Data to inform Retention Initiatives (Tameside and Glossop Integrated Care NHS Foundation Trust)
  • Best Health and Wellbeing, Rewards and Benefits offer (Kingston Hospital NHS Foundation Trust)
  • Best Support to New Starters and Newly Qualified (The Mid Yorkshire Hospitals NHS Trust)

 

The final award of the day, the coveted “Retention Team of the Year”; this award went to University Hospitals of Derby and Barton NHS Foundation Trust.

Congratulations to all the award winners, and those who were nominated.  The day was rounded off nicely by Professor Mark Radford, Chief Nurse for Health Education England and Deputy Chief Nursing Officer at NHS England and NHS Improvement providing an update on the National Retention Programme (see the website for more details). Retention of the nursing workforce, and other professional groups working in the NHS remains a huge concern amidst reports of workforce deficits and safe staffing issues. From this event it was evident that there are organisations working hard to make a difference not just for NQNs but for all nurses.

Team members in Vancouver

We have been capturing newly qualified nurses (NQNs) experiences of transition via interviews during the last 12 months. We recently had several discussions with international colleagues on this important issue and the challenges experienced by NQNs during this time seem to be common and occur in different countries – despite the different educational preparation, health care systems and policy and practice context. In addition, this experience also transcends professional disciplines and it is evident that this period of transition challenge also applies to different professions and disciplines allied to health. The importance of support during the transition period, as well as on-going mentorship and/or preceptorship throughout careers to deal with and process challenging emotional situations is fundamental to the wellbeing of healthcare staff. This is relevant to NQNs as well as more experienced healthcare professionals.IMG_6526.JPG

These conversations took place whilst we were attending the International Institute for Qualitative Methodology “Qualitative Health Research Conference” (25-29 October) in Vancouver. This was such a great experience – a diverse and eclectic inter disciplinary mix of keynotes and concurrent sessions exclusively focused on qualitative health research. A conference full of stimulating debate in a welcoming and supportive environment. This was an opportunity to showcase the qualitative elements of our study – the student reflections on transition in a poster presentation (Change Challenge and Excitement: Reflections on the transition from student to newly qualified nurse). We also did an oral presentation focused on the interview data from the study – ‘Perspectives on transition from student to newly qualified nurse views of students, NQNs, academics and clinical managers’.IMG_6556

Our work was well received with lots of positive feedback. It has provided us with some great ideas for future research and some food for thought on how we can further interrogate our research findings.

Supporting student nurses as they are preparing to move into the world of work

david-barrettDr David Barrett writes: As part of the STaR project work with our students and partners in practice, we have been exploring different ideas to facilitate the transition period, when students exit the university and move into the world of work. One of the ideas that came out from our interviews (with students and clinical leaders) was the need for an opportunity for students to meet their future colleagues and see their place of work prior to starting their newly qualified nurse (NQN) role.

“…it will give them the opportunity to meet people…you know the code for the door…silly little things, it will make them less anxious on the day they start”

“…I would always advise people to start somewhere where they have already had a placement, just for simple things like you know where the coffee room is…you know how things work …they know your work ethic…they know what you are like”

The message from interviews was very clear: students would benefit from spending time with their first employer ahead of qualification. It was suggested that this would promote familiarisation and orientation, allow pre-induction processes to commence, potential training needs to be identified and for the ‘transition shock’ of new employment to be reduced.

From a University perspective though, final placements with the first employer raises some issues. It is important that the decision of a sign-off mentor/practice assessor on a student’s readiness for registration is entirely objective. If the final placement (and final assessment) takes place on the area where a student will be taking up employment, this may compromise objectivity. Equally, students must be judged as competent to work in any area as a Registered Nurse, not simply the specialty or area in which they will commence employment. For these reasons, the policy of the University of Hull is not to give student final placements in the setting in which they will be taking up employment (though other Universities do allow this).

Nonetheless, the STaR findings demonstrated a desire to allow students some exposure to their place of first employment (PFE) during their final placement. As a compromise, an initiative was designed that would allow them to spend up to two weeks (75hrs) of their final 12-week placement working within their PFE. Their performance during this time would not be formally assessed, though supervisors could provide testimony that was fed back to sign-off mentors. The PFE initiative was developed and agreed with our main local employers, and first implemented in the summer of 2019.

Initial feedback from the project has been positive. Two-thirds of students took the opportunity to spend time with their PFE (reasons for not doing so included previously having had a placement there or the area being too geographically distant to be practical). We asked those who had spent time with their PFE to rate (on a scale of 0-10) how useful the time had been. Orientation to the area (mean score 8.3) was deemed the area in which the initiative was most useful, followed by building confidence (7.9) and understanding the RN role (7.7).STaR mentimetre

We also asked the students what they found most useful. Many students highlighted that the time enabled them to meet their future colleagues (and vice versa) – “Getting to know the staff”; “Getting my face recognised before starting”. For other, there were practical benefits – “…getting uniforms and shifts and booking holidays” – and the ability to become orientated – “Understanding the ward’s routine”. One unexpected ‘benefit’ was raised by five respondents whose time on their PFE made them realise that they had made a mistake in accepting the post: “I learnt I did not want to work there”.

There were some teething troubles with the initiative. Awareness amongst practice areas – particularly those further afield – could be better, and the processes for arranging and recording time with the PFE could be enhanced. We are continuing to review the student feedback, and that from our partners, to refine the process and governance around this but we are really pleased to see that the initiative has been broadly successful and seems to have helped some students prepare for the transition from student to employee.