The Mid Staffordshire Report

UNIVERSITY OF HULL, UK—In January, I referred to the Mid Staffordshire Foundation National Health Service Trust. On 6 February 2013, a final report of the Mid Staffordshire NHS Foundation Trust Public Inquiry included the following statement: “Between 2005 and 2008 conditions of appalling care were able to flourish in the main hospital serving the people of Stafford and its surrounding area.”

If you want to see just how badly wrong things can go in a nationalised system of health—the so called “jewel in the crown” of U.K. public services—read this report. Beware; it is 1,781 pages long, excluding the executive summary. Few will need to read every word, and fewer still will do so. Nevertheless, for a rapid assessment of the systemic, professional and personal failures that conspired to create the biggest scandal in the history of the U.K. National Health Service, the executive summary will suffice.

As a U.K. citizen and nurse, I am well aware of the problems in Mid Staffordshire. The U.K. media have had little difficulty in deciding what to headline in the past week, and there have been the inevitable swipes at nurses with degrees, another subject of past entries in this blog. While the public are provided with further depths to the scandal and shock and informed that no ‘heads have rolled’… yet (disciplinary proceedings may now begin), the professions are more concerned about the recommendations made by Lord Francis QC, who chaired the enquiry.

The recommendations are copious, and those related to nursing cover several pages. The range of recommendations covers the “whole nine yards,” from sublime common sense to the ridiculous type of ignorant knee-jerking that is so common when non-nurses comment on nursing. At the ridiculous end is the recommendation that the U.K. regulatory body for nursing, the Nursing and Midwifery Council (NMC), together with universities, should work over the course of several months to produce a system for testing the aptitude of nursing candidates, paying special attention to caring attitude and compassion. This ought to tie the NMC and university schools of nursing up for months deciding what to measure and how to measure it.

Surely, the three-year programme of undergraduate nursing education is at least partly supposed to weed out those unsuitable for nursing and also to mould those with promise into good nurses. I can see where Lord Francis’s idea stems from: 1) the ubiquitous driving force of the well-meaning public servant that “something must be done (about it)” and 2) that “there is something that can be done (about it).” There were manifest failures of medical and surgical care, yet there is not a similar recommendation that aspiring doctors be pretested for aptitude.

Giving credit where it is due, Lord Francis did make two excellent recommendations that would be easy to implement. The first of these, which seems uncontroversial but has eluded nursing in the United Kingdom since the mid-1980s, is a national standard for testing the competence of nurses to practice. While not wishing to use the tragic circumstances surrounding Mid Staffordshire to illuminate my own good sense and that of some close colleagues, it is interesting to reflect on some recommendations made by a few of us in 2002: “A clear finding (from this study) is that no single method is appropriate for assessing clinical competence. A multimethod UK-wide strategy for clinical competence assessment for nursing and midwifery is needed if we are to be sure that assessment reveals whether or not students have achieved the complex repertoire of knowledge, skills and attitudes required for competent practice.” I doubt we can take the credit now, but at least we can demonstrate that some nursing academics were making common-sense recommendations over a decade before Lord Francis.

The other excellent recommendation is that: “The Nursing and Midwifery Council and other professional and academic bodies should work towards a common qualification assessment/examination.” The United Kingdom long ago abandoned a national state examination for nurses but, again, along with a colleague, I have published the view that we should return to a national curriculum and a state examination for nursing. Surely, this is a recommendation worth pursuing.

This entry has been very U.K.-, not to mention self-, centred. March finds me in Hong Kong, Saudi Arabia and Canada, and also in front of my colleagues speaking about international strategy. I will also be delivering a paper on nursing leadership at a local event of the Honor Society of Nursing, Sigma Theta Tau International. I expect that next time I post, Mid Staffordshire will no longer be in the headlines and that I can report something that illuminates the best in U.K. and international nursing. Meantime, I contemplate approximately 25,000 miles of flying, jetlag and hotel rooms; actually, not the worst prospect.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

The apprenticeship sorcerers

UNIVERSITY OF HULL, UK—As the festive season approached, I looked forward to a fortnight away from work when I could safely read the U.K. newspapers without finding cause for alarm. The end of the year is usually reserved for funny stories, advertisements by charities and reflections on the past year. However, I was wrong.

On 27 December 2012, The Daily Telegraph featured a piece titled “Become a lawyer with no degree, pupils told,” and I realised I was not going to make it to the end of the year without controversy. I made an entry on my Twitter feed the next day: “UK government wants lawyers trained by apprenticeships not degrees – parallels with nursing? where will this go?” which elicited some responses from nursing colleagues and a lawyer I know well.

I was surprised that the nurses seemed less bothered about this thinly veiled criticism of university education than the lawyer! While I trained as a nurse under the apprenticeship model and enjoyed and appreciated every day of it, I have long defended the value and necessity of nurses having degrees and the fact that there is no evidence that having a university education reduces their ability to care. There is room for both aspects of preparation in the nursing curriculum.

I was actually more interested in what the response of the legal profession would be and, specifically, if nurses with degrees would feature in it. And guess what? There were several letters in reply and extensive entries in the letters page weblog under the banner “Qualifying for a profession without taking a degree – or running up debts” and, of course, both sides of the argument were represented.

There were two references to nursing, as follows: 1) “The Government may mean well by its plan for an apprenticeship route for traditional professions, but it is ill-founded. Unless other industries, such as hospitality and nursing, abandon the requirement for a degree, a peculiar imbalance will be introduced into the higher education system.” 2) “SIR – And while we are at it, can we also please return to apprenticeships for nurses?” I find it strange and infuriating that nursing is juxtaposed with the hospitality industry and is used as an exemplar of where university degrees are inappropriate. For my non-United Kingdom readers, I must say that this is a uniquely U.K. phenomenon; the value of degrees for nurses has never been questioned—in my experience—in the United States, Australia, the Far East or Southeast Asia.

It did not end there. The year was nearly over when The Sunday Times, never a great supporter of academic nursing, managed to include nursing in a retrospective swipe by Minette Marrin—foremost amongst our critics—at everything that had annoyed her over the year in a piece titled “Pesky clerics, Europhiles, nurses’ leaders – it’s all change for you” on 30 December 2012. Referring to the frequent reports of poor nursing care in the U.K. media, Marrin questioned the purpose of nursing leaders in the United Kingdom; easy and obvious targets, of course, but not the people directly responsible for the delivery of poor care that appears to take part in isolated pockets such as the Mid Staffordshire Foundation National Health Service Trust, where a bullying culture has developed and there is a general cynicism about continuing professional development—the very thing usually criticised by people like Marrin.

Therefore, 2012 ended on a slightly negative note from my perspective, but a new year lies ahead and, while reports of poor care and unwarranted criticism of academic nursing in the United Kingdom will continue, I have a lot to look forward to elsewhere in the world. In 2013, I will visit Italy, Finland, Canada, Bahrain, Hong Kong, China, the United States and Australia. I look forward to blogging from some of these places.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Meet Professor Sally Wai-Chi Chan!

SINGAPORE—I am spending a month in Singapore, the “melting pot” of Southeast Asia. Singapore is a melting pot for two reasons. First, the heat and humidity are excruciating. Even the mildest exercise outdoors induces profuse perspiration and laboured breathing. The only respite this time of year is the daily monsoon downpour, but even that is lukewarm.

Singapore is also a melting pot in another sense; it is one of the most multicultural places in the world. And it is entirely peaceful. Draconian sentencing and harsh punishments by the local judiciary tend to enforce good manners and tolerance. Nevertheless, appreciation of other cultures seems genuine. The place is fabulously rich with 17 percent of the population being millionaires (Singapore dollars).

This visit—my third to Singapore—is to the National University of Singapore, currently ranked No. 25 in the world in QS World University Rankings (No. 2 in Asia). Specifically, I am at the Alice Lee Centre for Nursing Studies, located in the Yong Loo Lin School of Medicine, recently ranked the top medical school in Asia by QS. Founded in 2006, the centre is led by Professor Sally Chan.

Sally Wai-Chi Chan

I have known Sally for more than 20 years, ever since we both arrived in Edinburgh. I was a new lecturer and Sally, along with her husband Bing-Shu Cheng, was a new MSc in nursing student. A decade later, we met again when Sally was working in the Nethersole School of Nursing at Chinese University of Hong Kong, where I had been appointed external examiner for their master’s in nursing programme. Thus began my frequent travels to the Far East and Southeast Asia and a rekindled professional relationship with Sally.

Sally is energetic, ambitious and productive. She has always been visible and vocal, both as a student and as an academic. Her leadership in mental health nursing research and the mark she made on delivery of services in Hong Kong is remarkable, and her output of publications is impressive. Sally was clearly destined for leadership, and she is now in a key position to lead the development of this relatively new centre and to contribute to academic nursing in Singapore.

I am lucky to benefit from being one of a succession of international visiting scholars and professors to the Alice Lee Centre for Nursing Studies. Sally has made it her trademark to work with the best and learn from the best. In turn, those of us lucky enough to come here frequently learn a great deal from the diligence, dedication and sheer hard work of the local academic and nursing population. Working days are long here, but the rewards are concomitant.

Sally is an outward-looking, horizon-scanning person, and this was recently exemplified by her visit to my own University of Hull. At present, Singapore does not allow nurse prescribing, but an ageing demography, together with nursing and medical-personnel shortages, will necessitate some new approaches to delivery of care and some shifting of professional boundaries. Sally wants to be at the forefront of this change, and the purpose of her visit to the United Kingdom was to learn about nurse prescribing programmes—Hull was a pioneer in this respect—and to see what links could be formed to help prepare her for advancing this initiative in Singapore.

Leadership

Leadership is hard to define but obvious when you see it. It is demonstrated in many ways and under different circumstances. The circumstances in Singapore could not be more ready for leadership such as that displayed by Sally Chan and, as a result of her far-sighted thinking in pursuing an academic career in Australia and the United Kingdom, (largely outside her native Hong Kong), she could not have been more ready for her current leadership role.

I often ponder my own leadership skills and wonder if the opportunity awaits me to demonstrate them; it has eluded me to date! Next week finds me in Bangkok and then Hong Kong before I head home to the UK for Christmas. In the meantime, at leisure, I think about the vagaries of professional and academic life, and where better to do so than the world-famous Long Bar of Raffles Hotel in Singapore.

"Barman!"

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Impacting the impact factor

UNIVERSITY OF HULL, UK—The impact factor, a proxy measure of journal quality using citations, is often maligned and rarely praised. Nevertheless, it is studied avidly and regularly. And when there is evidence of journal editors blatantly trying to manipulate it by artificially increasing the number of citations to their own journals in their own journals, it creates controversy. However, all editors of journals cited in the impact factor league tables keep a close eye on impact factor and make—legitimate—efforts to ensure that they maximise their opportunities to maintain and improve their positions. It is well known, for example, that review papers, methodological papers and controversial papers (even ones that are wrong) are rapidly and highly cited and make a significant contribution to impact factor.

What is the impact factor?

The impact factor is a measure of citations (A) in a given year (e.g., 2011) to particular papers (B) published in the previous two years (e.g., 2009 and 2010). The impact factor is A divided by B. Excluded are contributions such as correspondence and editorials. However, it is worth noting that citations in these entities do contribute to A.

It is also worth noting that papers cited in a particular year from that year—2011 papers cited in 2011, for example—do not contribute to the impact factor. In fact, papers cited within their calendar year of publication have no effect on the impact factor. Therefore, if editors want to play the impact-factor game—legitimately—it is obvious that they must: 1) publish as many highly citeable papers as possible; 2) increase citation of them by generating comment in letters and editorials (within reason) and 3) time the publication of citing entities properly. For example, an editorial that cites a paper published in 2011 is better published in January 2012 than December 2011. It must be noted that Thompson Reuters, who “owns” the impact factor, does police the process and look for anomalous patterns of citation.

Can editors influence impact factor?

The answer is, clearly, yes. However, how long does it take an editor—say, one appointed in January 2011—to influence the impact factor of a journal, and is this a legitimate measure of editor performance? In the year of appointment, an editor has no influence on impact factor because the metrics, which are based on the previous year, are already fixed.

In the second year of appointment, the editor has minimal influence, because only one year’s worth of material published under his or her tenure may be considered for citation, and a high proportion of this is likely to have been accepted by the predecessor. However, measures taken in the second year to increase citations to the journal’s content can have an influence, but only to the extent that they reference the one year’s worth of content controlled by the new editor.

In the third year of appointment, all material published in the previous two years and some of the year preceding is the responsibility of the editor, and any measures taken to increase citations in that year are restricted to those two years.

Only in the fourth year of appointment can the editor take full responsibility for citing content and content being cited in the journal. Therefore, following appointment, it takes four years (until the end of 2015, using the present example) for an editor to significantly affect the impact factor.

If measures taken are successful, the editor is lauded and is safe in the job. If measures taken are not successful, the publisher has a dilemma: sack the editor in the knowledge that his or her successor will take four years, fully, to influence the impact factor, or continue with the same editor in the hope of improved performance.

Things usually continue with little change for a year after an editor’s contract expires and a new editor is hired. Therefore, my conclusion about impact factor is that, while it is a controversial measure of journal quality, it is a useless measure of editor performance.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. 

'You have to have an assessment!'

HONG KONG—I am easily irritated by what I take to be stupid comments or questions, especially ones that convey a bureaucracy with which I don’t agree.

“You have to have an assessment” was the response in Hong Kong when I tried to use an indoor climbing wall.

“But I’ve been climbing for nearly 30 years,” I replied.

“You have to have an assessment!” was the firm response with that “the-issue-is-now-closed” look that the charming but invariably inflexible person behind a desk in Hong Kong conveys so well.

“Can I have an assessment?” I asked, conceding that safety is an important issue and that they had no proof I could climb safely.

“You have to make an appointment” was the reply, at which point I turned and walked out, deciding that my training regime would have to be suspended during this trip to the Far East.

The incident reminded me of a friend who graduated as a nurse in the United Kingdom and, after moving to Hong Kong, was required to pass a local exam prior to practicing. As she had graduated from my own alma mater (Edinburgh) and from the school where I first taught, this offended me ... until!

We do exactly the same in the United Kingdom to all incoming nurses; we even ask native English-speaking nurses (North Americans and Australians) to take an English language test (IELTS or TOEFL) to quite a high standard before they can register. They also have to have a period of induction prior to practice. The Australians have reciprocated by insisting that incoming nurses also take an English test, including native UK nurses.

I have mixed feelings about the need for all this assessment and for the resulting assessment industry that has grown up around it (a view I won’t be expounding on too much at the reception I’ve been invited to attend by the Commission on Graduates of Foreign Nursing Schools during the upcoming meeting and annual conference of the American Academy of Nursing in Washington, D.C.). I can see that safety is paramount, and guaranteeing the competence and educational level of everyone arriving from a foreign country with a nursing registration is crucial and, probably, impossible without a formal approach. However, when I arrive in Washington, DC, as I could do here in Hong Kong, I can produce my driving licence and hire a car with the likelihood of killing a great many more people than if I turned up to work as nurse. This is only an analogy. Nursing is infinitely more complex than driving, but the principle applies, and I see no efforts in any country to streamline and accelerate the processes.

I have no solution to the problems encountered by nurses who wish to migrate or just gain experience outside their own country. In fact, I can acknowledge that there is a need for some “barriers” to free movement of registered nurses. I know very well how a rash of scandals involving non-native nurses in the United Kingdom leads to calls for tighter regulations. In addition to protecting patients, these regulations protect the nurses from beyond our borders who are practicing safely and making a major contribution to our National Health Service. All this is notwithstanding the fact that registered nurses from anywhere within the European Community can work in the United Kingdom without let or hindrance, including an English language test.

So, I did not manage to do any climbing in Hong Kong. But if you have read this entry to my blog, I hope you will think I have made reasonably good use of the time that was freed up.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

I could almost be a nurse!

UNIVERSITY OF HULL, UK—“I’ve had so much contact with nursing over the past few years I could almost be a nurse.” This statement, or a slight variant thereof, has been uttered in my presence in each of the four universities where I have worked and in others where I have undertaken quality assurance or other external work. The protagonist is, invariably, male; a member of a university senior management team; and coincidentally, I presume, an engineer. Perhaps engineers are more adept than most at “engineering” their way into the higher echelons of university management, but I’ll have to consider that possibility another day.

Before entering nursing, I studied biochemistry at the bachelor and doctoral levels. However, I long ago gave up all pretensions about being a biochemist, not due to modesty, but lest I get “caught out” by a hard question. In the same vein, I have never heard fellow nurses, even though many have been in senior university positions and with significant exposure to other disciplines, claim that the exposure led them to consider themselves “almost a physicist,” “almost a philosopher” or “almost a mathematician.” So, what is it about nursing that leads people to say these things, and what should our response be?

My guess about why people in these positions say these things is that it is due to a subconscious—I am being generous—attitude of superiority about their chosen discipline whereby what they do is considered difficult, and nursing is considered easy. I can only guess further that their image of nurses is immobilised in stereotypes: feminine; middle class; not highly educated; and “caring.”

I would not wish to dress nursing up to be something it is not. Nursing is a practice-based discipline that lies at the crossroads of several disciplines that include life sciences, social sciences and medicine. Nursing, as a subject, may not grapple with the origins of the universe, solving the world economic crisis or designing iconic buildings. Nevertheless, we do deal with the origins of someone’s distress, finding a solution to that stress and helping rebuild people who may become iconic in their own right. And we don’t just do this once, but many times a day and hundreds of times a year.

We don’t do it alone; we work in partnership with many professions and have to know more about them than they ever seem to know about us. It may look easy but, reflecting on my own clinical practice many years ago and the kinds of problems I currently address in my research, it certainly doesn’t feel easy.

My response to statements such as the one at the top of this post used to be a polite laugh; followed by a stony face and then a grimace, with an inwardly expressed gratitude that the person found their métier elsewhere. I have, more recently, decided to return to smiling and inwardly expressing gratitude that, however easy it seems and however hard it actually is, I found my own métier.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.