Letter from the editor

Published: 07 September 2011

‘Deceit and a poor sense of value.’ These were the words of Nick Clegg, talking recently about the problems that beset our land in many areas of public life, namely politics, banking, and the press with the Murdoch affair.

His words could apply equally to the nursing profession, as we have had to suffer the horror and humiliation of watching so-called carers maltreat and abuse their vulnerable patients.

The Coalition Government has had a very hands-off approach towards regulation but one cannot help but wonder now if this will become moderated. Politicians are currently unanimous in their demands for transparency, accountability and agreed standards of practice that should be beyond reproach in all domains of the establishment.

So,where does this leave ANPs?

Still crying in the wind for all those things – a rigorous means of evidencing our standard of practice, and of ensuring that all those practitioners of nursing at this advanced level can demonstrate the same training and education. Why is this so vital? Because without it our patients cannot trust us to deliver safe and effective care. Trust is what this is all about, and why the public have been so shaken by all the recent revelations, not just about Murdoch et al but especially when nurses or carers, the very people we are entrusted to when at our most frail and vulnerable, abuse that power.

We are all in this together: what we permit, we promote. So if any nurse sees a colleague treat a patient with anything less than sensitive, compassionate and highly effective care, then we are duty bound to respond. Nurses are, and always have been, their patients’ advocates, and primum non nocere – first do no harm – is our most basic directive.

If the recent harsh lessons tell us anything it is that there is a risk that instead of leading and inspiring people to perform at the highest level of behaviour that human beings can aspire to, all too often individuals and organisations sadly fall very short of this, and instead reflect the baser instincts of the times.

The old triad of responsibility, accountability and authority must be observed and each domain weighted equally. Thus, in advanced practice, we first of all need a delineation of our roles and responsibilities: there must be openness about what it is that we can do for our patients, and what should therefore be expected.

Second, to perform our responsibilities or scope of practice safely we need the authority to do so. This means having the correct qualifications, and being delegated the responsibility by our employers. “Ay, there’s the rub,” as the Bard might have said: can employers always be trusted either to know how to judge the level of competence of their ANPs, or to have the correct available information upon which to make their decision? How much easier would it be if our ultimate conferrer of authority to practise, the Nursing and Midwifery Council (NMC), were to make a ruling about the expected standard of advanced nursing practice? Some might very well think that currently the NMC is abrogating its own responsibility here and failing to protect the public in its persistent procrastination of regulating advanced practice.

Finally, one cannot be fully accountable for one’s actions or omissions if there is no agreed clarity on the scope of responsibilities and if the authority has not been appropriately conferred.

A better society

In conclusion, “I agree with Nick”: let us call for a better society where there is a return to the highest values of integrity and where deceit and poor performance are eliminated as far as possible. To do this as nurses we need to show our patients that we can be trusted to care for them at all times safely, effectively and with utmost respect and dignity. We also need to remember that we all stand or fall together: we need to co-create a culture where high performance is encouraged and rewarded, and this can only be achieved by working in effective teams and with strong leadership.

'Alpha patients'

And now for something completely different: have you ever had an ‘alpha patient’? This is someone who has turned your practice or your way of thinking about an aspect of nursing on its head.

I have taken this term from a novel by a doctor called Martin Winckler. The hero in the novel is a surgeon who is forced to re evaluate her role as a doctor caring for her patients. It is a French book so was an interesting insight into health care across the channel but there were many issues that ring true in the UK. One of the themes was how as healers (interestingly the French word “soignant” is interchangeable for nurses and doctors) we have to “accompany” patients and not judge or lecture them. As a nurse working in general practice and being ruled with an iron fist by the Quality Outcome Framework, I welcomed this thought: how much of the patient agenda these days is relegated to what we address once we have done our opportunistic health promotion? How much of this is intrusive and unwanted? We seem to be increasingly asked to perform from a public health perspective but can this always be reconciled by addressing the specific needs of the patient in front of us?

Treatment choices

Recently in the British Medical Journal there was an interesting letter entitled ‘Cost of preventive drugs: dare to tell?”, by Michael Trewby. It explored the value of preventive medicine and how much we involve our patients in making choices about their treatment. Now, of course, health is largely what we do to ourselves, but medicine prides itself on not accepting the status quo but in changing risks and probabilities with the aim of making the patient healthier (if not happier).

As someone famously said, the genes load the gun but the environment pulls the trigger, and our job is to help patients put that damn gun down. But of course medicine is far from easy to discern. So we now talk of treating populations and not necessarily the patient in front of us. The greatest good to the greatest number type of argument. Certainly with recent rise in measles and potential horrendous sequelae from the drop in herd immunity it is easy to see the sense in this. But some areas are much more blurred and can be open to debate – for instance, the primary prevention of CVD and the treatment of osteoporosis. The letter in the BMJ quotes the NNT (number needed to treat) as 667 on oral biphosphanates to prevent one fracture and that 99.8% of patients treated will not receive any benefit from the drug. Amazing! So the authors ask whether we “dare to tell” the patients these facts and figures. What, I wonder, is the NNH ( number needed to harm)  from biphosphanates?

My conclusions: merely that health is very complex and multi-factorial and that maybe our first task as clinicians is to empower patients to help themselves. Sometimes it feels like prescribing drugs allows us to take short cuts (for example, SSRIs in depression) when it’s life that needs changing. I know I prefer four ballet classes a week to protect my bones and the calcium in my milk and cheese intake to alendronate and calcichew (pirouettes, not pills!).

This, however, is my choice and another individual will choose medication. So maybe the task is to support the patient to help him or herself knowing that we don’t know it all and that in the future medical advances will cast scorn on many things we do today in the name of good, evidence-based medicine – and of course that’s without even discussing the role of big pharma companies and the potential of influence from that huge powerful industry.

Get in touch

I have a request to make of you, dear reader: do you have an “alpha patient” you want to share with us? A memorable patient who changed your practice or made you re-evaluate what you do and how you do it? If so please email me: ghislaine.young@bradford.nhs.uk

We all have a responsibility to shape our practice and to influence others, not just respond to government or the prevailing medical dogma unthinkingly. And so often it is our patients who show us the better way to practise.

Ghislaine Young

References

Trewby PN (2011) Cost of preventive drugs: dare to tell? BMJ 2011; 342: d3198
Winckler M (20019): Le Choeur des Femmes. Collection Folio. Gallimard.