“Factfulness is … recognizing when a scapegoat is being used and remembering that blaming an individual often steals the focus from other possible explanations and blocks our ability to prevent similar problems in the future” – Hans Rosling
A few weeks ago, Harriet Sergeant caused a Twitter backlash by condoning a letter written by a member of the public to The Times newspaper. The man expressed his view that when nursing started to become a degree only profession, “that’s when the rot set in”. This opinion was shared by Ms Sergeant who then took part in a Twitter debate with enraged healthcare professionals from all backgrounds. It was difficult to tell what people were more incensed about; the claim that nursing had become a “rotten” profession or the view that nurses don’t need degrees because all we do is put patients on bedpans. I expect it’s a bit of both. I watched the debate unfold like an origami swan but declined to get involved myself. I did, however, say that a response was pending. This, dear readers, is my response.
Now, let’s talk about PPI. Not the stuff you were mis sold by your bank, but Patient and Public Involvement. PPI in research terms is different to having patients and the public as participants in the research. It means that they are involved in the research design process and possibly in data collection and analysis. This may sound like a farfetched branch of research for the more liberal and creative of us, but it is actually vital when it comes to healthcare. Our patients and the public have the ability to see our services through a different lens and this matters when the service exists for the public in the first place. It’s also essential to ensure understanding from the bottom-up when changes are made in the clunky cogs of an enormous engine like the NHS.
Nursing degrees have existed since the 1980’s, but in 2009 the decision was taken to abolish diplomas altogether and make nursing a degree only profession by 2013. Why was this decision taken? Simply put, the demands, responsibilities and roles of nurses has changed and is continuing to change. This means that as well as all the tasks and procedures that we have always undertaken, nurses also need analytical and critical thinking skills because we work more autonomously and independently than ever. Given that everyone on Twitter seemed obsessed with bedpans for some reason, I will use the example of assisting a patient to use one to illustrate the change in nursing philosophy over the last 50 years or so.
In circa 1970, Matron would come over and sternly tell you that Mrs Bloggs requires a bedpan. As the nurse, you would diligently go to the sluice, warm the metal bedpan with hot water and then somehow single handedly help Mrs Bloggs onto it. When she was finished, you would remove the pan, scrape the contents into the metal lavatory in the sluice and sterilise the bedpan ready for the next patient who required it.
Today, Mrs Bloggs will ring the bell and ask me for a bedpan. My first question will always be “can you use a toilet instead if I help you?” This is not because I’m too posh to deal with bedpan contents, it’s because bedpans are horrid, undignified and uncomfortable and I know I would rather use a toilet if I could. If Mrs Bloggs cannot use the toilet due to immobility or another limiting factor, I will go to the sluice and collect a cardboard bedpan. Nowadays, they are disposable because nursing research has indicated that this drastically reduces the risk of transmissible infections. Before helping Mrs Bloggs, I will wash my hands using the seven step technique outlined by the WHO to ensure I don’t miss any potential bacteria that I could pass on. This didn’t exist in 1970. At this point I would encourage Mrs Bloggs to do as much as she can to help me and herself onto the bedpan. This is not because I’m a mean nurse who won’t help my patients when they need me. This is because nursing research has shown that encouraging patients to move reduces their risk of skin breakdown, promotes independence, reduces the risk of secondary infections and blood clots and reduces the risk of me injuring myself, or Mrs Bloggs, by moving a fully grown adult on my own. If Mrs Bloggs is unable to get herself onto the bedpan with my assistance, I will call a colleague to safely move her with me. Once Mrs Bloggs is on the bedpan, I will wash my hands again to prevent transmission of infection to my other patients. When Mrs Bloggs has finished on the bed pan, I will wash my hands and put on a pair of disposable gloves and an apron. Decisions on whether to wear personal protective equipment are made based on the Epic3 guidelines for infection prevention and control which are updated every few years to reflect best practice as discovered by ongoing research into the subject. When I remove the bedpan, I will note the following: the condition of Mrs Bloggs skin, the ease with which she is able to move herself in the bed, the telltale crumbs in the sheets that tell me she has been eating biscuits despite being diabetic and of course, the contents of the bedpan. This requires its own assessment. What colour is the urine? What colour is the poo? Are there smells that shouldn’t be there? Is there blood? Is Mrs Bloggs constipated? Does she have diarrhoea? Is there as much urine as there should be? When did she last use the bedpan? How does this compare? Honestly, if you’ve ever tried to dine with a bunch of nurses, you will know that we are not in the least bit squeamish about body fluids, even if there is food on the table and polite company present. After all this, I will dispose of the bedpan in the macerator, remove my gloves and apron, wash my hands again and document what I have done and use the information to decide on next steps. Does Mrs Blogg need pain relief? Does she need a laxative? Does she need a special mattress to protect her skin? Do I need advice from a dietician? Is she dehydrated? How is she going to get home? Does she have carers? How many of those biscuits did she eat? What is her blood sugar now?
Ms Sergeant stated “I can assure you that giving a patient a bedpan hasn’t changed”. Hopefully, you can now see that this is an unfounded and incorrect statement.
Several paragraphs ago, I mentioned PPI and at this stage you are probably wondering why. Let me explain. I am not angry with the gentleman who said that the rot had set in. Not in the slightest. It is not his fault that he holds that view. Several workforce evaluations have been carried out over the last 30 years, many of them led by the Kings Fund or Nuffield Health. These reports make recommendations for how we can best ensure that our healthcare workforce is equipped to manage changing health and population needs for the future. The focus is on the safety and well-being of patients and staff. Many of them make reference to involving “key stakeholders”. None of them say who these people are and none of them have involved patients or the public. Read the description of giving Mrs Bloggs a bedpan again, but this time, consider it from her perspective. Is it obvious that I am using research to inform my decision making? Is it clear that I am making multiple assessments at one time? Does she know that her experience of using a bedpan in 2019 is far safer than it was in 1970? In all likelihood, she does not.
We cannot expect our patients and the public to understand our role if we don’t involve them in the conversation in the first place. Aggravating opinions are an opportunity for discussion and education. Our service users deserve a say on how their tax money is spent and what they expect from us. It’s called democracy. But people cannot be expected to make informed decisions and opinions without the information they need to do so (we only need to look at the Brexit debacle to see how important that is!). So let’s give it. Our degrees have provided us with the skills to conduct critical and analytical conversations with a huge range of people from different walks of life. Let’s use them. It’s time to speak up and speak out as a team and in partnership with the very people that depend on us. Science, not slander.