The UK National Health Service: What about nursing?

/ Peggy L Chinn / 6 Comments

We are delighted to welcome this message from Elaine Maxwell, addressing the current challenges facing nurses and nursing in the UK National Health Service (NHS).  Her message has world-wide implications!

I am one of those nurses, I think the NHS is a wonderful jewel built on a shared sense of equality and justice (and I have worked briefly in private healthcare both in the UK and in the USA). The challenge for the NHS is that there are different opinions on what it is there for and how to evaluate it. Discussions are more often focused on

Elaine Maxwell

Elaine Maxwell

ideology (socialism versus market economies) that what the staff within in actually do.

The Commonwealth Fund (2014)1 rated the NHS as first internationally for effectiveness, safety, patient centeredness, cost and efficiency and third for timeliness of care. In spite of this, successive UK governments of both main political parties have focused on cost savings and faster access.

Starting in 1997 with the New Labour Blair Government, the definition of a good service moved from a broad base to focus on access and cost. Targets were introduced for waiting times for both emergency and elective care and organisations incurred financial penalties for failure to achieve them whilst at the same time they had to cut unit costs in order to become quasi autonomous ‘Foundation Trusts’. Something had to give and in the NHS it was nursing.

Nurses failed to articulate their therapeutic contribution and some enthusiastically embraced the role of managing patient flow to achieve access targets. This was a tangible, visible contribution to the new managerialism agenda as opposed to more opaque, but critical, nursing interventions. This lack of visibility led management consultancies to recommend wholesale cutting of nursing posts, for example McKinsey advised that nursing posts could be cut in London to save £421 million a year without any impact on the quality of the service2.

This perfect storm was exemplified by the failings at Mid Staffordshire NHS Foundation Trust and described in detail by the public inquiry3 which clearly laid the blame for many of the failings at the feet of nurses. Although the report detailed the swingeing cuts in nurse numbers prior to the failures, it also suggested (without any empirical evidence) that academic nurses with the ‘wrong’ values had been recruited and that potential nurses should work as unregistered care assistants before being allowed to study. Despite concerns from nurses4, this idea is being piloted in the NHS and a recent BBC programme demonstrated that nurses and students have bought into this rhetoric5

Following the publication of the report, the Government commissioned a review of Trusts with apparently high mortality rates6. These ‘Keogh’ Trusts were found universally to have ‘insufficient’ nurses and those that recruited significant numbers of nurses have improved their quality outcomes the most.

So UK nursing is currently confused. There is a belief that increasing the number of registered nurses improves quality as demonstrated by Aitken and colleagues7 but this type of cross sectional correlation study does not explain what it is that nurses actually do to create this quality. The Chief Nursing Officer for England has focused on individual nurses’ values with her strategy ‘Compassion in Practice’8. The Quality Improvers, with a nod to LEAN thinking, are focused on the getting patients through the system faster with nurses managing the flow so that medical staff can provide their clinical intervention. No one, it seems, feels that nurses have a unique therapeutic contribution and nurses who trained at a time when Henderson’s definition of nursing was embraced and who learnt and practised nursing models are now in the twilight of their careers.

With increasing numbers of people with multiple co morbidities, the traditional episodic medical treatment model looks increasingly unlikely to meet the needs of our population but without nurses who actually nurse, more and more people are readmitted to our hospitals and so the vicious cycle of speeding up the flow intensifies.

When Margaret Thatcher sought to reorganised the NHS in 1983, her advisor said “In short, if Florence Nightingale were carrying her lamp through the corridors of the NHS today she would almost certainly be searching for the people in charge”9. I contend that if Florence Nightingale were carrying her lamp through the corridors of the NHS today she’d be asking “Where are the nurses?”

So what can nurses do about it? We need to reclaim our area of practice and make it visible by articulating our unique contribution, which is often tacitly shared amongst nurses and patients but policy makers and managers can be entirely oblivious to it.

We need to use the language of those with power and describe how nursing is more than a support service to medicine. Nursing has its own independent added value that can realise benefits for organisations as well as patients. The Dutch community nursing service, Buurtzorg10 has done this by ensuring that care is led by highly educated RNs who work autonomously with few protocols. This model has been independently audited and shown 40% reduction in cost of service with improved quality scores as nurses have been empowered to direct their work to where they add the most value; nursing not management. When we speak this language, we connect with others and the value of nursing can be understood and celebrated

1 Commonwealth Fund (2014) Mirror, Mirror on the Wall: How the US Health Care System compares internationally  www.commonwealthfund.org

2 Nursing Times news report (2012) http://www.nursingtimes.net/nursing-practice/clinical-zones/management/london-hospitals-told-they-could-slash-nursing-bill-by-421m/5041068.article

3 Francis, R. (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry London: The Stationery office http://webarchive.nationalarchives.gov.uk/20150407084003/http://www.midstaffspublicinquiry.com/report

4 Maxwell, E. (2013) Francis inquiry: compulsory work as healthcare assistants won’t make better nurses British Medical Journal, 346

5 Grumbling Appendix blog   “Do Not adjust your (mind) set “ 25th July 2015 https://grumblingappendix.wordpress.com/

6 Keogh B (2013) Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report London: NHS England http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/Overview.aspx

7 Aiken, L. H. et al (2014) Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study The Lancet 383(9931), 1824-1830

8 Commissioning Board Chief Nursing Officer and DH Chief Nursing Adviser (2012) Compassion in Practice: Nursing, Midwifery and Care Staff Our Vision and Strategy. London: Department of Health NHS Commissioning Board. http://www.england.nhs.uk/wp-content/uploads/2012/12/compassion-in-practice.pdf

9 Griffiths R (Chair) (1983) NHS Management Inquiry London: HMSO www.sochealth.co.uk/history/griffiths.htm

10 http://buurtzorg.com

Nurses Who Soar Like Eagles

/ Peggy L Chinn / 3 Comments

This post contributed by Adeline Falk-Rafael

For the past several years I have taught leadership to internationally educated nurses in a 4th-year BScN course. Given professional and disciplinary expectations that nurses demonstrate leadership, regardless of their practice role, the course is designed to provide related knowledge and skill development through classroom and experiential learning.

 After the initial exploration of contemporary leadership theories we begin development of some related skills, the first being communication and collaboration. At the outset of the eaglecourse, students are assigned to a group of 7 or 8 students. Each group is expected to complete a project by the end of the term, but the primary purpose of the group is to provide an opportunity for applying leadership principles and practicing related skills, such as effective communication, (for more information, see my “Peace and Power blog post) 

 It is the difficulties that students experience in this practice and application that provides an opportunity to reflect on why that is – on how we have been taught to how to act, communicate and be in relationship as nurses in the health care environment and women and men in our society. It is about at this time, that I show them the parable of the chicken and the eagle, which you can watch below!

The basic premise of this parable is that a young eagle has found itself in a chicken yard and learns to believe it is a chicken and thus behaves like a chicken. Although I have seen various versions of this parable, in this particular one, although an eagle tries to “mentor” the young bird into realizing its potential as an eagle, it retreats into the safety of the chicken barn to live out its life as a chicken.

My belief is that it is irresponsible to emphasize the professional imperative for leadership without examining some of the systemic barriers to enacting that leadership; what stands in the way of us fulfilling our potential as eagles, how have we been taught to think of ourselves and behave as chickens – or less than we are? It is only in recognizing the barriers that we can begin to discover ways of overcoming them. Throughout the remainder of the course, it seems that whether we are speaking of communication, collaboration, advocacy, change agency, conflict resolution, or visioning for the future, we encounter “chicken” messages or confining structures that need to be overcome before we can soar like eagles.

What keeps us from working to our full scope of practice, for example? Is it the safety /comfort/ security of working within a defined job description? To what extent have we internalized an identity of an ancillary medical worker?

What keeps nurses so often from being acknowledged as credible knowers? In 2003, I was President of the Registered Nurses Association of Ontario, during the SARS outbreak in Toronto. At one point, officials deemed the outbreak over, but nurses in one hospital began seeing patients present with the same symptoms and warned of possible new cases. They were silenced with the words, “if I need an expert, I’ll ask for one.” (For more information, see “Lessons Learned from SARS”)

Ceci,1 in a brilliant analysis of the proceedings of an inquest into the deaths of 12 children who underwent cardiac surgery at the Winnipeg Health Sciences Centre, in Manitoba, Canada, similarly described dismissals to nurses’ repeated expressed concerns with the competence of the surgeon, leading the judge presiding for the inquest to observe that the nurses eventually silenced themselves. Ceci concluded: “nurses were presumed to be, acted upon as if they were, the sorts of persons whose concerns need not be taken seriously and gender ideology was a resource that could be strategically drawn upon to make the presumption true” (p. 76).

My guess is that most nurses reading this would be able to recount similar incidents, although more than 10 years have passed since these events. It is a challenge to keep believing and acting like an eagle when you continually get messages that you are a chicken! It is all too easy to become discouraged and give up but in the words of May, “What becomes important for nurses is not that we somehow expect that we may free ourselves of the effects of gendered, gendering discourses, but that we begin to understand how these work in constituting our experiences, . . . that we begin to understand their hold on us and try to make choices about what, if anything, we want to do about this” (cited in Ceci, p.80)

1Ceci, C. (2004). Gender, power, nursing: A case analysis. Nursing Inquiry, 11(2), 72-81.

 

 

Response to White Coat Ceremonies for Nurses

/ Lisa Sundean, PhD, MHA, RN / 7 Comments

Welcome to Lisa Sundean, who is joining our team of bloggers!  

Lisa Sundean

Lisa Sundean

WCCs originated in 1993 by the Arnold P. Gold Foundation. The purpose of the WCC is to symbolize the transition into the medical practice and to remind medical students of their promise to scientific, compassionate medical care. Since 1993, several other health professions have adopted the WCC as a professional milestone and transition for students. More recently, nursing schools have begun to adopt WCCs, endorsed and supported by AACN in partnership with The Arnold P. Gold Foundation (The Arnold P. Gold Foundation, 2013).

On the surface, the symbolism of the WCC for health professionals is honorable. However, one must question the utility and deeper meaning of the WCC for nurses. First, the WCC originated for the medical profession. Are nurses still so enamored by medicine that we cannot embrace our own professional symbolism and rituals? Second, nurses understand the struggle of the profession to rise up from more than a century of medical oppression and yet, we are willing to don the white coat of physicians as a symbol of achievement and transition in the nursing profession. Are we not cloaking our students in the very cloth of oppression we seek to emancipate from? Finally, as we face the critical need to transform healthcare, we fully understand the importance of interdisciplinary and interprofessional collaboration. Such collaboration capitalizes on the unique synergies of knowledge, skills, and expertise of various disciplines and professions. Is the WCC contrary to such collaboration? Does the WCC unconsciously invoke nurses to become more like physicians rather than the unique profession it seeks to become; a profession with a unique knowledge base, a unique skill set, a unique expertise, a unique contribution to health and healthcare, and a unique set of professional traditions?

The WCC is a new tradition for the medical profession. It is fair to respect the symbolism of the ceremony for physicians. However, adoption of the WCC for nurses is questionable. Nursing scholars encourage us to find our professional voice and establish our professional uniqueness (Kagan, Smith & Chinn, 2014). The quest for that uniqueness is a road paved with rigor, creativity, dedication, and commitment to the metaparadigm of nursing. With all due respect to The Arnold P. Gold Foundation, nurses, we can do better than allow ourselves to be seduced by a medical tradition to symbolize our unique profession and identity.

References

Kagan, P. N., Smith, M. C. & Chinn, P. L. (2014). Philosophies and practices of emancipatory nursing: Social justice as praxis. New York, NY: Routledge.

The American Association of Colleges of Nursing. (July 2015). Gold Foundation and AACN to fund 60 nursing schools for 2015 white coat ceremonies. Retrieved from http://ymlp.com/zwDmlO

The Arnold P. Gold Foundation. (2013). White coat ceremony. Retrieved from http://humanism-in-medicine.org/programs/rituals/white-coat-ceremony/

The Endocannabinoid System: What Nurses Need to Know, An Introduction

/ Carey S. Clark, PhD, RN, AHN-BC, RYT, FAAN / 11 Comments

Medical cannabis is now legal in 23 states and Washington DC, along with recreational cannabis also being legal in several states. Many patients and families are now relocating to Colorado and Washington State as “marijuana refugees” (http://www.nbcnews.com/business/consumer/marijuana-refugees-looking-new-homes-pot-legal-states-n22781), knowing they can freely and safely access cannabis as medicine in these recreational cannabis states. Nurses may still wonder, how is cannabis “medicine”?

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As nurses we have a lot to learn about cannabis, including how it works in the mind-body-spirit system, and how we can best advocate for and support patients who could or do benefit from this medicine. Last spring, I witnessed a brief presentation being given to nurses around medical cannabis use, and it was obvious from the questions asked by many of the nurses that the social stigma around “marijuana” was alive and well. Would these nurses be so reluctant to accept and support medical cannabis use if they truly understood the endocannabinoid system (ECS)?

The ECS was discovered some time ago, with  Dr. Ralph Mechoulam (Faukner, 2015) being a pioneer in this area in the mid-1990’s. There are 20,000+ scientific articles written about the endocannabinoid system (ECS). Though it has been many years since the discovery of this body regulatory system, most nurses likely know very little, if anything, about the ECS. Truly, this is a problem, nurses are more likely to know the xarelto lawsuit phone number by heart over the benefits of ECS.

A functioning ECS is essential to our health and well being. Endocannabinoids and their receptors are found throughout the body; in the brain, organs (pancreas and liver), connective tissue, bones, adipose tissues, nervous system, and immune system. We share this system in common with all other vertebrate animals, and some invertebrate animals (Sulak, 2015). Cannabinoids support homeostasis within the body’s system; the ECS is a central regulatory system, cannabinoid receptors are found throughout the body, and they are believed to be the largest receptor system in our bodies. Cell membrane cannabinoid receptors send information backwards, from the post-synaptic to the pre- synaptic nerve. CB1 (found primarily in the brain) and CB2 (mostly in the immune system and in the bones) are the main ECS receptors (Former, 2015), though several more are currently being studied. The exogenous phytocannabinoid THC, or the psychoactive compound in cannabis, works primarily on CB1 receptors (hence the “high feeling” in the brain), while the cannabinoid CBD works primarily with the immune system and creating homeostasis around the inflammatory response through CB2 receptors and does not have psychoactive effects. Other cannabinoids and their actions are still being studied, such as the non-psychoactive cannabinoids CBN and CBG, also found in cannabis.  Our bodies react to both our own production of endogenous cannabinoids and to the ingestion of phyto-cannabinoids found in the cannabis plant, and other non-pyschoactive plants such as Echinacea. To read more about the science behind the ECS and endocannabinoid receptors, the following are excellent resources:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2241751/

http://www.ncbi.nlm.nih.gov/pubmed/16596770

Endogenous Cannabinoids: Endocannabinoids are the chemicals our own bodies make to naturally stimulate the cannabinoid receptors;  anandamide and 2-arachidonoylglycerol (2-AG) are two well known endocannabinoids (Sulak, 2015) that are produced by the body as needed, though not stored int he body. The body produces these endocannabinoids in a similar fashion to how it produces endorphins (Pfrommer, 2015), and activities such as exercise support the endogenous production of cannabinoids. Endocannabinoids are also found in breast milk and in our skin. Alcohol interferes with endogenous cannabinoid production.

Phytocannabinoids: In general, we think of the cannabis plant as the generator of exogenous cannabinoids that we can ingest in a variety of ways, namely psychoactive THC (works with the CB1 receptors in the brain- and also in the gut) and non-psychoactive CBD (works with the CB2 receptors in the immune system and the gut). Other plants such as Echinacea also produce non-psychoactive cannabinoids and work with the ECS to support health and well being through homeostasis (Sulak, 2015).

Cannabinoid Deficiency Syndrome: It should be clear that everybody makes cannabinoids and everybody needs cannabinoids to function. People who do not make enough cannabinoids need to supplement with exogenous cannabinoids through cannabis ingestion, in much the same way that an diabetic needs insulin supplementation making it a “Natural Energy Powder,” in which it is good for your health. Dr. Ethan Russel’s (2004) publication on Clinical Endocannbinoid Deficiency explains this particularly well: http://www.nel.edu/pdf_/25_12/NEL251204R02_Russo_.pdf

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Homeostasis:

Cancer: “Cannabinoids promote homeostasis at every level of biological life, from the sub-cellular, to the organism, and perhaps to the community and beyond. Here’s one example: autophagy, a process in which a cell sequesters part of its contents to be self-digested and recycled, is mediated by the cannabinoid system. While this process keeps normal cells alive, allowing them to maintain a balance between the synthesis, degradation, and subsequent recycling of cellular products, it has a deadly effect on malignant tumor cells, causing them to consume themselves in a programmed cellular suicide. The death of cancer cells, of course, promotes homeostasis and survival at the level of the entire organism” (Sulak, 2015, paragraph #7). Cannabinoids support apoptosis and suppress cancer tumor angiogenesis (McPartland, 2008).

Heart disease: Additionally, it has been stated that the ECS plays an important function in protecting the heart from myocardial infarction and cannabinoids can have anti-hypertensive effects (Lamontagne et al, 2006).

Inflammation: When inflammation occurs, the ECS helps to stop the process, similar to applying the brakes on a car. This is why cannabis is proving to be good medicine for inflammatory related illness. “Activation of CB2 suppresses proinflammatory cytokines such as IL-1β and TNF-α while increasing anti-inflammatory cytokines such as IL-4 and IL-10. Although THC has well-known anti-inflammatory properties, cannabidiol also provides clinical improvement in arthritis via a cannabinoid receptor–independent mechanism” (McPartland, 2008).

PTSD: “This review shows that recent studies provided supporting evidence that PTSD patients may be able to cope with their symptoms by using cannabis products. Cannabis may dampen the strength or emotional impact of traumatic memories through synergistic mechanisms that might make it easier for people with PTSD to rest or sleep and to feel less anxious and less involved with flashback memories. The presence of endocannabinoid signalling systems within stress-sensitive nuclei of the hypothalamus, as well as upstream limbic structures (amygdala), point to the significance of this system for the regulation of neuroendocrine and behavioural responses to stress. Evidence is increasingly accumulating that cannabinoids might play a role in fear extinction and antidepressive effects. It is concluded that further studies are warranted in order to evaluate the therapeutic potential of cannabinoids in PTSD.” (Passie et al, 2012).

Seizures: Most hopeful, cannabis has been used to support pediatric treatment-resistant epilepsy, and while more research needs to be done in this area, many parents are becoming medical marijuana refugees by moving to states where they can procure cannabis for their children who suffer from seizures.

Co-agonists:Cannabis increases the pain relieving effects of morphine, as discovered by researchers at UCSF. The two medications are synergistic, and this provides great hope for patients suffering intractable pain at end of life, chronic pain suffers, and opiate addicts. (http://www.maps.org/research-archive/mmj/Abrams_2011_Cannabinoid_Opioid.pdf)

For Nurses: So as nurses, what do we need to know to support patients who use cannabis?

Legal issues: If you live or work in a state that has legalized medical or recreational use of cannabis, familiarize yourself with the laws in that state, as well as your own workplace policies around supporting patient’s use of medical cannabis. Patients may have questions and as a patient advocate, your responsibility is to support patients with their knowledge and use of this medicine within the confines of your practice setting and state laws. You should also be aware of constraints around your role as a nurse in supporting patient use of medical cannabis. For instance, Kaiser patients in some states are likely to be removed from chronic pain patient programs if they test positive for cannabis. Nurses with knowledge around the benefits of medical cannabis can also advocate to support shifts in such policies will no longer align with the emerging ECS science.

Safety: This goes along with the legal aspects; medical cannabis patients should be supported in how to manage and store their medications with safety. While cannabis is known to be extremely safe (far safer than opiates and alcohol), cannabis consumers still need to store medication out of reach of children and pets. They should be supported in knowing the safety of driving or operating machinery if they consumer THC- based cannabis medicines. They also may need information on cannabis testing for both THC: CBD ratios, pesticides and/or other hazardous materials. Many patients need assistance with the basics around medical cannabis use, such as dosage, ratios of THC: CBD, strain information, and ingestion methods.

Overcoming Stigma: Unfortunately, a stigma was created around around cannabis during the process of prohibition in the 1930’s, which was largely financially and racially driven. Contradictory state and federal laws, and the stigma around smoking cannabis (though many cannabis patients can now get relief from vaporizing using the best vape pen for oil, drinkable tinctures, topicals, wearable patches, and edibles), along with a clear ignorance around the body’s ECS, serve to further the stigma associated with medical cannabis. Educate yourself on the roots of the prohibition of the medicine:

http://origins.osu.edu/article/illegalization-marijuana-brief-history

And other issues around stigma and cannabis myths:

http://alibi.com/feature/48426/Erasing-Stigma.html

http://sandiegofreepress.org/2014/05/12-of-the-biggest-myths-about-marijuana-debunked/

http://www.huffingtonpost.com/mary-hall/weed-the-people-movie-loo_b_5501864.html

American Cannabis Nurses Association: There are many nurses actively involved in supporting the use of medical cannabis and the defining the nurse’s role in this process. The ACNA has a mission to advance excellence in cannabis nursing practice through advocacy, collaboration, education, research, and policy development. http://americancannabisnursesassociation.org/

In Israel, nurses actively support patients in cannabis consumption from the process to the dosage.

http://www.tabletmag.com/jewish-news-and-politics/137423/medical-marijuana-kibbutz

Nurses’ supporting patients healing process through cannabis medications may someday be common place in the USA as well.

References:

Lamontagne, D., Lepicier, P., Lagneux, C. & Bochard, J.F. (2006). The endogenous cardiac endocannabinoid system: A new protective mechanism against myocardial ischemia. Arch Mal Coeur Vaiss.,99(3), 242-6.

McPartland, J.M. (2008). The endocannabinoid system: An osteopathic perspective. The Journal of the American Osteopathic Association, 108, 586-600. Retrieved from http://jaoa.org/article.aspx?articleid=2093607

Passie, T, Emrich, H.M., Karst, M., Brandt, S.D., & Halpern, J.H. (2012).Mitigation of post traumatic stress symptoms by cannabis resin: A review of the clinical and neurobiological evidence. Drug Test Anal. 2012 Jul-Aug;4(7-8):649-59. doi: 10.1002/dta.1377. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22736575.

Pfrommer, R. (2015). A beginner’s guide to the endocannabinoid system: The reason our bodies so easily process cannabis. Retrieved from http://reset.me/story/beginners-guide-to-the-endocannabinoid-system/.

Russel, E. (2004). Clinical Endocannabinoid Deficiency (CED): Can this concept explain therapeutic benefits of cannabis in migraine, fibromyalgia, irritable bowel syndrome, and other treatment resistant conditions? Neuroendocrinology Letters(25), 1-2, 31-40.

Sulak, D. (2015). Introduction to the endocannabinoid system. Retrieved from http://norml.org/library/item/introduction-to-the-endocannabinoid-system.

Freedom

/ Wendy Marks, DNS, ANP-BC / Leave a comment

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According to Miriam Webster Dictionary freedom is a noun, and defined as the quality or state of being free. Freedom is the absence of necessity, coercion or constraints in choice or action.

Life, liberty and the pursuit of happiness are the hallmarks of independence. To be liberated from the constraints and restraints of the power from another, or a set of beliefs, yields a quality of life that allows for ease of speech and privilege to be and become what we want.

As nurses, we may experience coercion or constraints, even restraints in our practice. Can we liberate ourselves and define our set of beliefs to have the power to see and say what nursing is and is not?

Contemporary theorists and healers believe we may start by setting the intention for the highest healing good to occur; then see nursing within the context of a set of beliefs and values that promote caring and healing for self, system and others; we take action to liberate our selves and others of the constraints and restraints that bind us from achieving this end.

What is it like to live and work in environments that allow freedom of speech and action? Are we brave enough to challenge those who seek to imprison us in thought and behavior? Is nursing is the home of the free and the brave; or are we constrained  by restrictive rules, mores and narratives?

In my research on caring and healing I have heard nursing narratives that describe transformative advocacy; looking, and seeing where the next right action enfolds … taking the next steps together, with each other, and our patients and families down a new yellow brick road that meets each persons next Freedom.

Nursing, the home of the Free and the Brave; let Freedom reign.