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Nurse Training

Volume 501: debated on Wednesday 18 November 2009

Motion made, and Question proposed, That this House do now adjourn.—(David Wright.)

I am delighted to have secured this extremely timely debate. As a constituency MP, I am contacted by constituents who are dissatisfied with the service that they or their families receive in hospital, and the question of nurses’ training often arises. Therefore, following the announcement that from 2013, entry to nursing will be at degree level, this is a good opportunity to highlight those concerns.

I want to make it clear that I do not agree with some of the more politically motivated criticisms of the Government’s plans. I fully recognise the great strides made by our Government in restoring the NHS to full health. Since 1997, we have seen record spending on health, reversing years of Tory underinvestment. We need not take any lessons from the right about how to run our NHS. Our NHS has been not a 60-year mistake, but a 60-year success and triumph.

I also acknowledge that some critics of the Government’s plans seem to be motivated by sexism. My hon. Friend the Under-Secretary of State for Health is concerned about that. The chief nursing officer for NHS England, Dame Christine Beasley, said:

“There is still an issue that because nursing has some of those feminine caring skills, people think anyone can do it. It’s a very sad reflection of a male dominated media”.

I oppose any criticism of the Government’s plans that is based on sexism. My mother was a nurse in the first generation of NHS-trained nurses in 1948. Anyone who knows my family knows that it would take a very brave person to belittle in any way the role of women.

I also want to make it clear that I do not raise this issue out of any impulse to attack the Government. Loyalty to the Labour party is another trait that is in my genes. In 12 years I have never voted against the Government, and have no intention of doing so.

Motion lapsed (Standing Order No. 9(3)).

Motion made, and Question proposed, That this House do now adjourn.—(David Wright.)

However, I do think that it is the role of constituency MPs to inform the Government of grass roots feelings in order to enable Ministers to make the best decisions. Since 1997, the status and pay of nurses has risen, and thousands more nurses have been employed. This has gone hand in hand with a massive growth in health spending. When I think back to the 1990s under the Tories, when patients died on trolleys in corridors at my local hospital because there were not enough beds, I know how good it is that today’s debate is about how to give people the best possible care, rather than about whether we can give them any care at all. Nobody has to wait 18 months for an operation. But with such massive investment also comes great responsibility. Particularly in times like these, it is vital that we get as much as we can out of the public purse.

Residents in parts of my constituency have a life expectancy eight years lower than those in neighbouring constituencies. More babies are born with low birth weights there, and morbidity is high. Life for many people is hard. Given the chaotic lives of some of my constituents, the care that they receive from nurses can make a vital difference to their life expectancy. That is why any changes in the way that nurses are recruited and trained cause such anxiety. Nursing is not just a medical job. It involves interpersonal, communication and care skills. However, despite all the investment in training in recent years, the complaints that I receive are rarely about nurses’ top-end medical skills. They are nearly always about care.

Sadly, one of my most supportive Labour party activists, Alf Jones, died last year. He was a popular man with my stuffers—a group of older Labour party members who help me fill envelopes and fold newsletters. After visits to see him on Barrington Brooke ward at St. Helier hospital, the stuffers complained repeatedly to me about the care standards that they saw there. They described an elderly man left at night with faeces on his nightshirt for everyone on the ward to see; patients not washed; full urine bottles left lying around; dirt on the beds, stairs and landings; patients ignored despite screaming and crying; a lack of privacy; the frequent loss of false teeth; and patients who could not walk being expected to use a zimmer frame.

The stuffers were so shocked that they asked me to arrange a meeting with the hospital’s chief executive, which I did. As a result, a member of staff was removed, and increased training and supervision was given to the ward team. The stuffers are now regularly invited on to the ward to see for themselves that standards are being maintained.

Mr. A is another Labour party stalwart, who has devoted most of his life to the care of vulnerable people. Now in his 80s, he was admitted to St. Helier with an infection. While in accident and emergency he became incontinent and was mortified that he was not given the appropriate privacy. Then, when he was admitted, he had nightly battles with his nurse. Every night she would want to take off his cardigan, which kept him warm, and his hearing aid, but without his earpiece he suffered from unbearable tinnitus. He became so scared of the nurse that he asked to leave.

Mrs. H contacted me about her 92-year old mother. While she was in St. Helier, they would not let her go to the toilet, even though she could walk a little, and could manage fine once she had been wheeled to the door. She was forced either to go in her bed, or be put up in a hoist and dangled over a bedpan, with two members of staff standing by to cheer her on, shouting, “Come on, push!” or, “Clever girl.” While she was in accident and emergency, one nurse inserted a cannula so badly that her wrists and arms were covered with bruises. Mrs. H also said that while she was visiting another ward she spotted a golf ball-sized piece of faeces. Despite pointing this out to staff at Sunday lunchtime, she noticed that it was still there on Monday evening. Apparently, it was finally cleared at 11am on Tuesday.

Mrs. H wrote a very moving letter to me. She said:

“Maybe the ‘walk a mile in my shoes’ philosophy should be drummed into all medical students at the beginning of their training, and underlined throughout to prevent this very sad downward trend in care”.

She continued:

“Today it is 3 years in University, and once qualified they are let loose on the wards, and if the computer cannot tell the nurses what to do it is not done. Today we seem to have nursing by machine. Machines cannot talk to patients; patients cannot talk to the machines. The intermediary has to be the nursing staff, and....the nursing staff were sadly lacking in their experience with coping with older people.”

In August the Patients Association published its report “Patients not Numbers, People not Statistics”, which detailed a further 16 cases of neglect and poor care, including catheter bags not being changed, cold patients in wet beds who had been forced to wet their beds because they had not been taken to the toilet, and elderly, confused patients being shouted at by staff. The association’s president, Claire Rayner, is well known as a nurse. She describes herself as being

“from a generation of nurses who were trained at the bedside and in whom the core values of nursing were deeply inculcated.”

She laments any reduction in those values. Although the association admits that only 2 per cent. of patients rated their care as poor, it points out that that represents more than 1 million cases of what Ms Rayner calls the

“dreadful, neglectful, demeaning, painful and sometimes downright cruel treatment”

that some elderly people have experienced.

The problem is well articulated in the report by Julie Bailey, whose mother Bella had an appalling experience. She said:

“When we complained about all this to the Trust they told us that they had a new initiative that would provide guidance on standards of care regarding communication, nutrition, privacy, dignity and record keeping. Surely after three years of training, nurses should be aware of these basic needs and how to set their own standards?”

My constituents want more rolling up of sleeves and delivering of common-sense caring. This was brought home to me by another Mrs. H and her daughter, who happens to be a practising nurse. They came to see me about Mrs. H’s mother, who was a patient at St. George’s hospital. They had found her mother in soiled clothing, with other night clothing covered in faeces hidden away in her locker. She was in dirty and unhygienic conditions, and it was clear that she was being neglected. Her colostomy bag was not changed when required, and documentation about her fluid and food intake was not kept up to date. When Mrs. H and her daughter complained to the ward sister, they found that a nurse had tried to alter the drug chart. On another occasion, a nurse confronted Mrs. H and her daughter, addressing her in south London terms as “Girlfriend”, which I do not think any of us would regard as acceptable.

Mrs. H wrote to me to say:

“I have concerns about the organisation of the staff...and the lack of care and skills with patients. Staff should not have to be retrained in how to record notes, how to speak to patients and their relatives. Staff should have that knowledge already.”

Mrs. H did have one good thing to say, however. She said:

“There was one genuinely friendly person on that ward. She was a nursing assistant called Sharon who always took the time to speak to the patients and their relatives. I feel that it doesn’t take much to show humanity.”

That is the crux of people’s concerns about the Government’s proposals. They want nurses who speak to them and who show humanity. They do not want compassion and humanity to come second to classroom-based teaching, and they do not want anyone who has those qualities to be put off the nursing profession.

In an article in “Spiked Online”, the head of engagement and patient involvement, a sessional nurse in NHS London, Brid Hehir, argues that

“the most fundamental aspect of nursing—caring—has been degraded and devalued. Bedside care has been devolved to health care assistants. It’s as if bedside care is no longer the remit of nurses.”

She accepts that in previous decades nursing was undervalued, but she is not convinced that the solution is more academic training. She goes on to say:

“Prior to 1992...nurses spent only a quarter of their training in the classroom and three quarters on the wards...They are now expected to learn through supervised participation—observing but not participating.”

As a result,

“many nurses qualify with nothing like enough skills, knowledge, clinical and practical experience.”

She goes on:

“The problem can only get worse if university-based training becomes the norm because the emphasis will shift further to theoretical aspects of caring as opposed to its practical application.”

This relates closely to the concerns of my constituents.

The person who bathes a patient needs to have enough medical knowledge to spot physiological problems. For instance, a nurse might find that a patient is gaining or losing weight. They might find dry skin, which is a sign of dehydration. They might find bed sores, or other wounds such as bruising. Of course, a porter or a health care assistant could just as easily bathe a patient, but would they have the medical understanding to appreciate what these signs mean?

Even nurses themselves are divided. On the Nursing Times website, there are more than 100 readers’ comments about the article entitled “All new nurses must have degrees”. Most think that the degrees will not improve the profession. It is true that some believe that this will raise standards and that if a few would-be nurses do not qualify, so be it. However, I have to say that that is not a sentiment that I—or, it seems, most Nursing Times readers—share. My mother was not a graduate, but she was an excellent and conscientious nurse, able to care and read someone’s medical records.

As one nurse in a similar position says:

“I don’t think I am capable of degree-level learning on any course…I simply don’t learn effectively by writing thousands of essays. If this decision was made a year ago, I would not be able to gain a nursing qualification.”

Another says:

“I work with nurses who have two degrees but do not even know what is normal body temperature. They have excellent computer skills but lack oral communication skills or simple people skills.”

Another complains:

“Obviously, the people with influence don’t read any of the comments on here by ‘real’ nurses, otherwise I doubt they would go ahead with the plans for degrees only nurses. Most of us have said that fundamental basic skills that underpin nurses are ‘hands on’ and need to be learned at the bedside, not in the classroom.”

I hope this reassures her that some people do read her comments. I am not sure whether I am a person “with influence”, but I hope that this helps.

Another nurse says:

“I studied for 2 years at Diploma…and then transferred to Degree. This lowered my bursary considerably and upped my academic responsibilities. No change in my ward responsibilities…The stress of this extra workload nearly made me, and several colleagues, give the course up. I made my choice to transfer to degree as I was led to believe promotion was more likely with it. However, this does not seem to be the case in practice.”

I think we need to be careful about nurses becoming disillusioned.

That comment brings me to the high risk of drop-out rates. According to today’s Times:

“More than half of students on some nursing degree courses do not graduate because of the pressures of time, money and the academic standards demanded.”

Although I do not get cases of students dropping out of college very often, most of the cases I deal with are students of nursing. Many colleges seem extremely tough; some students with legitimate personal troubles that have prevented them from doing well in exams are excluded because colleges will not take those troubles into account. Indeed, many who drop out do not have English as their first language, so perhaps the colleges have their own problems with communication and care, which need addressing.

Meanwhile, of those who do pass—although I do not think that we should take too many lessons in caring from the Daily Mail—the former nurse Rona Johnson writes in it that

“many nurses, armed with their new qualifications, will regard the basics of care as demeaning… Those who have spent three years at university and run up heavy debts will not take kindly to emptying bed pans or changing bed linen.”

She sums up the fears of many of my constituents in the expression “too posh to wash”. Of course, this is a simplistic expression, based on prejudice as much as fact, but the Government have a lot to do if they are to convince my constituents that we will not end up with a generation of nurses who are great at medical strategy, but no good at rolling up their sleeves.

For instance, a survey in the Nursing Times uncovered nurses who were

“rejecting essential elements of bedside care because they feel it is not a worthwhile learning experience.”

The magazine says that one student told a staff nurse:

“I keep being asked to do things which won’t help me learn—clear up poo, mop up blood, give patients tea and toast… I don’t do those sort of things now.”

Thankfully, most Nursing Times readers reject that view, but the way we train nurses should not encourage it.

I hope that my hon. Friend the Minister will view this debate as a positive contribution to how to improve the quality of care for our patients. I have not come here to attack the profession or to perpetuate a sexist portrayal of “angels”. Nor have I come to be disloyal or disrespectful to a Government who have always aimed to do the best for our constituents. What I want is for nursing to be one of the country’s top vocations and for nurses to be trained in full. As Brid Hehir says:

“Caring for sick people is a privilege and nurses need to be competent in providing it. When they are, their status will automatically improve.”

My constituents will say amen to that.

I congratulate my hon. Friend the Member for Mitcham and Morden (Siobhain McDonagh) on raising, as she put it, a timely and important issue, and thank her for doing so. She has spoken with characteristic passion for justice and equality, providing many examples this evening of circumstances where her constituents have not had a satisfactory experience in their hospitals, and my hon. Friend has taken up those cases—again, with her customary strength and commitment—with the local health service. She described cases that were, as she put it simply unacceptable—and I entirely agree with her. She is right to challenge such examples wherever and whenever they occur, and she is also right to emphasise the importance of training and the enduring values of nursing. I am pleased to have this opportunity of addressing directly the concerns that she has raised.

Nurses represent the largest staff group in the NHS. They work in a more diverse range of roles and settings than ever before. They are pivotal to the delivery of high-quality, safe care. There is hardly an intervention, treatment or health care programme in which they do not play a significant part.

As we all know, the environment in which all our health care professionals work, including our nurses, is changing. Society, the structures within which health care is provided and, indeed, health care delivery itself are changing. Some types of care that are currently provided in hospitals will be provided in the home or in communities. Technology is becoming more advanced; people are living longer, and therefore health needs are often more complex; and people’s expectations are changing and growing. We have come a long way since the stereotypical days, if they ever really existed—my hon. Friend referred to them—when a nurse was expected simply to mop the fevered brow or provide a sympathetic ear. Nursing today requires an intricate interplay between fundamental care and high-level technical competence, biomedical knowledge, decision-making skills, and the ability to develop therapeutic relationships based on compassion as well as holistic and intelligent care.

It is in that context that we must examine the way in which we educate our new nurses, to ensure that they are equipped to deliver high-quality care now and in the future. No profession stands still, and nursing is no different. It has always adapted and responded to new demands. I think it right, in that context, that the Nursing and Midwifery Council has reviewed nurse education, and last week the Department of Health announced our timetable for implementing the resulting changes. It is in accordance with the recommendations of the council, the body that represents nurses, and it involves ensuring that by 2013 all nursing programmes are degree-level and meet the new knowledge, skills and assessment standards being developed by the council. Universities, working with health care employers, will need to revise their curriculums so that those standards, delivered at degree level, provide new nurses with the skills and knowledge that they need in the transformed NHS.

I want to use this opportunity to dispel a few myths—I think that my hon. Friend used the word “prejudices”—that have been bandied about in the last few days, many of which detract from the hard work, skills and dedication of nurses past, present and future. Nursing is not the younger, less intelligent sister of medicine but a profession in its own right, with its own body of knowledge, its own evidence base and its own principles and values. Our nurses will always need to be compassionate and to care. They will still need to undertake care tasks that are an essential part of their role. That will not change with degree-level education. I can reassure my hon. Friend that students will still spend 50 per cent. of their time on the wards. Those students will be in the community working with patients and their families, learning on the job and being mentored by registered, practising nurses.

No profession has a monopoly on caring, but we should not be defensive about the fact that caring alone, vital as it is, is not enough to make a good nurse. Our nurses will still need to have the values—treating people with dignity, having empathy and demonstrating compassion—that we expect of a nurse. That is why we are working with the university sector and the national health service to strengthen the way in which we recruit our nursing students, the NHS’s future lifeblood.

All nurses will still be trained to undertake the essential nursing activities that underpin good patient care and promote health. Keeping patients clean and comfortable, and ensuring they are fed and have enough to drink, will still be an essential part of the nursing role. I hope I have given my hon. Friend and her constituents sufficient assurance that such tasks will be a key element of the work of nurses of our national health service.

However, nurses will also be educated to complete a detailed assessment and analysis of people’s health care needs, be they physical, mental or social, and to diagnose, refer, prescribe care or, indeed, intervene themselves as appropriate. Many of our nurses already do this. All nurses continually develop their practice, and many operate well above the level of their original qualifications while still providing the basics of care.

It is worth remembering that more than 30 per cent. of our nurses have degrees already, and we should recognise their significant contribution. Many have obtained them as part-time students, often while working full time over a number of years. Nurses often say that they did not realise the positive impact having a degree would have on their nursing practice, and how much they have improved services for patients as a result. Therefore, the move to degree-level education is in some regards a recognition of the fact that many nurses already operate at this level, and of their professional contribution and status.

Some critics have rightly identified that making nursing degree-level will present a challenge to those who do not have traditional academic qualifications or cannot afford to do degrees. The Department starts from the position that nurses must receive the right education, of both content and level, to equip them to provide high-quality care. We must only recruit those who have the ambition and talent to become excellent nurses. With this principle in mind, we must also ensure that we support and promote wide access to degree places for those who may come late to nursing, for those who may need a bit of extra support and for those who have already developed health care-related skills and knowledge in the workplace, such as health care support workers. Therefore, we are building on good existing practice at national level, and developing with the further and higher education sectors and employers new access routes through, for example, apprenticeships, national vocational qualifications and foundation degrees. In addition, the NMC is looking to increase the amount of previous academic and practice learning that can be recognised from the current one third maximum up to one half, and hence shorten a programme. That will provide more opportunities for those with relevant, valid experience without their having to go back to square one. We are also tackling the student support arrangements, to make sure that they are fair and do not present any barrier to people who wish to train in nursing or the other health care professions. To support the changes I have outlined, we are also putting in place action to promote nursing as a career. We must attract more nursing applications from people who will make the best nurses and stay in the profession.

We have also published a preceptorship framework to help ensure that our newly qualified nurses have protected time and expert support to help quickly develop the confidence to make the transition to effective practitioner. We have provided the service with an extra £20 million to support preceptorship provision.

In addition, we have published a framework for post-registration nursing careers, mapped against patient pathways, to support a more flexible and competent workforce and equip nurses with the skills and capabilities they require for the future. The framework can be used to demonstrate the wide range of career opportunities in nursing and support the promotion of nursing careers. Together, these developments provide the right direction of travel if we are to fulfil our ambition to provide higher quality care for all. I want to ensure that the intended benefits of changes to pre-registration nurse education are fully realised. Our patients and the public deserve nothing less. Therefore, officials in the Department are working with the national health service, the trade unions, universities, strategic health authorities and the regulator to develop a national implementation plan. All of this links to a wider vision for the profession and for what needs to be done collectively to carry it forward into the future.

Since the launch of the Prime Minister’s commission on the future of nursing and midwifery in England, the Department has been engaging with, and listening to, the public, nurses, midwives and professionals. We asked what people wanted from the nurses and midwives of the future, what skills and competencies they should have and what barriers they may face. We have received an overwhelming response—there have been more than 2,500 individual and organisational responses. The commission has reflected on the responses and developed a vision for the future, identifying some hot topics areas where it wanted further debate to take place. Since the beginning of October we have been debating this vision statement and listening to people’s views in response to the hot topics at a series of events across the country and via a range of channels to ensure that the final result resonates with nurses, midwives and other health workers, as well as with the public.

Our vision of nursing and midwifery set out the future that the commission wants to see. Our ultimate goal is that all nursing and midwifery staff fulfil their potential to help service users, families and communities to achieve the best possible health and well-being. We also foresee a future in which nurses and midwives will take centre stage in all aspects of health care and in which nursing and midwifery practice will continue to be rooted in compassion and dignity. Among the hot topic debates, we have been debating how to ensure that the transition to degree-level registration is successfully implemented to enable the nurses of the future to deliver the care that patients want and deserve. The commission will include that important issue in detail in its report.

We value our existing nurses for their contribution now and in the future. We require them to undertake continuing professional development, and we know that many of them have the skills and knowledge to work above the level of their original qualification. We must also recruit nursing students who have the ambition and talent to be excellent nurses. We must maintain a wide access to education programmes for those who may have traditional qualifications and have come to nursing late. I believe we owe that to not only the nurses, but the patients and their families who rely on our national health service to deliver the excellent quality of care that we require for ourselves and for the whole community.

Question put and agreed to.

House adjourned.