In the Midst of Life

by Jennifer Worth

  Question (from ‘Everyman’): So who does the basic nursing these days?

  Answer (information gleaned from CQC documents): Health Care Assistants.

  Q: And who trains them – the RCN?

  A: No. The employer, the Trusts, the NHS Training Authority, the care home, the agency or an independent hospital.

  Q: What training could the Trust give, for example?

  A: This can vary. Some trusts offer up to six weeks induction and training, whilst others provide two weeks of support for new Health Care Assistants.

  Q: What training would a private hospital, clinic or care home give?

  A: There is no national standard, and on the whole it is very little, a couple of days at most. However, all health care workers must show the Criminal Records Bureau clearance, and complete a brief induction.

  Dear Heaven, it can’t be true! And we had fifteen months’ training in basic nursing.

  I have two nieces who are health care assistants. One of them told me that she had worked with disabled children, and decided to change to geriatric nursing. She said, ‘So the agency sent me on half a day’s training.’

  ‘What!’ I gasped. ‘You can’t be serious!’

  ‘Yes, that was it, half a day. But remember, I had had experience in caring, and I had done some home visiting, too. If I hadn’t, I suppose they would have sent me for a whole day, perhaps even two.’

  So it is true.

  Induction consists of three parts, which can be completed in a morning:

  1. Fire drill, conducted by a fire officer

  2. Moving and handling

  3. Protection of vulnerable adults.

  ‘Moving and handling’ is instruction in how to use the winches, slings, pulleys etc., required for moving or lifting an immobile or helpless patient. Some of this equipment can be very complicated, and the company that makes these gadgets supplies a video instruction on the correct use. The purpose is to protect the employers and suppliers from claims of injury to nurses or care assistants from moving or handling patients incorrectly.

  ‘Protection of vulnerable adults’ is basically looking at different kinds of abuse, such as staff bullying or manipulating patients, or thieving. It is a video documentary, made by professional actors with advice and short, acted scenes of what can be done, and what one should not do. The purpose is to protect the employer from claims of malpractice. The video takes about forty-five minutes to run.

  National Vocational Qualifications (NVQs) have been available since the 1970s. They are based on national standards of practical competence in a wide range of occupations (over 1000) varying from bricklaying to hairdressing to catering.

  In 1988 the Healthcare Review Body (now the CQC) examined the position of carers, and, as a result, the NVQ training was started for prospective health care assistants. This is essentially a qualification in practical skills, and the training is on-the-job experience. There are three levels of achievement, trained, monitored and assessed by …

  Question (from ‘Everyman’): … by whom?

  Answer (from my research): It could be that the trust has a nurse-led training, followed by supervision of practice by a qualified assessor, and then both internal and external verification by an awarding body such as the City and Guilds.

  Q: What is the training for care assistants in private hospitals or clinics or in nursing care homes?

  A: This will depend on the organisation. In theory, a nurse on the staff should train and monitor care assistants. But, in practice, this is unreliable because some employers will take a carer after a day’s induction and there may be no nurse available to offer further training. There can be a wide difference between the training and supervision of care assistants in NHS hospitals and those employed privately.

  Q: If the private establishment has no nurse to train potential carers, who does train them?

  A: National Care Training Providers.

  Q: And what training do they offer?

  A: Telephone help throughout the day.

  Q: So is it seriously proposed that basic nursing can be learned by telephone?

  A: It is a telephone support line.

  Q: Is this support line open at night?

  A: No. Care assistants also have one-to-one contact with a specially trained NVQ Care Assessor.

  Q: How often is one-to-one contact available?

  A: By appointment, when it can be arranged.

  I have mentioned my two nieces who are HCAs. The younger one is on NVQ Level 3, and her elder sister is on Level 4. I asked the younger why she did not take the Level 4 qualification. She replied: ‘I don’t see the point. I wouldn’t earn any more.’

  ‘But it says here in the syllabus that you would.’

  ‘It may say that, but I wouldn’t get it.’

  ‘What do you earn now?’

  About £5.40 an hour. It might be £$.70 – I’m not sure.’

  Her sister interrupted: ‘I was on £5 something an hour for years and years, even after I passed Levels 2, 3 and 4; it made no difference to the pay But now I get £8 something an hour because I have worked there for a long time. That makes a big difference.’

  My nieces both work in nursing care homes, one in Reading, the other in Plymouth. I asked them why they did the work for such a pitiful wage. They replied, almost in unison, one echoing or agreeing with the other:

  ‘Because I love it.’

  ‘It is deeply satisfying.’

  ‘I love knowing that I have made a difference to some old person’s life who might be lonely or unhappy.’

  ‘At the end of the day, or night as it might be, you feel you have done something worthwhile.’

  ‘It’s very rewarding work.’

  I looked at them with deep respect. I have always loved them both, but had no idea of the depth of their vocational commitment and unselfishness. Sue, the older sister, is a very thoughtful and impressive woman. She is a Jehovah’s Witness, which is a life-affirming religion, and she bubbles with laughter half the time, and radiates warmth, kindness and compassion, which she says, in a large part, has come from her faith. She sees it as God’s commandment that she should be a Witness by working for those in need. I am sure she would work for nothing if she did not have bills to pay.

  I sent this chapter to them both for approval and had a letter in reply from Sue containing the following paragraph:

  I have chatted with Jayne and we are both of the same mind, that maybe we gave you an unfair description of our training, which I must make clear is always ongoing throughout our working life in the units we are employed in. There are always updates in line with CQC and care standards. We are not nurses but care assistants who provide a vital role in the physical and emotional care of the people who for one reason or another find themselves in care homes or day centres such as ours.

  This is the ideal standard, expressed by two ideal care assistants, and I know it to be true; the CQC, with support and advice from the RCN, is all the time striving to improve standards through on-going training. However, the stark fact is that a huge number of people working in private hospitals, clinics and nursing care homes have no training whatsoever, and do not stay long enough in the job to benefit from the training that may be on offer.

  Nursing Care Home Managers are supposed to employ only people with NVQ Level 3 qualifications. However, a survey conducted for the End of Life Care report, issued by the National Audit Office in November 2008 (p.6, sub para 15) found that fewer than five per cent of nursing care home staff had this minimum qualification. Why, then, are they employed? The reason is because the managers are desperate for staff. They must have someone to cover the varying shifts over twenty-four hours, and night duty is the hardest to get anyone for. They could not function if they insisted on this Level 3 qualification.

  An NVQ seems to be the minimum qualification that is obtainable. But it can be bypassed altogether. Agencies offer a bit of training that amounts to shadowing another carer for a few hours,
and this is accepted as enough for someone to get a job.

  It seems to me that care assistants fall into one of three categories:

  1. Those who are wholly and selflessly dedicated.

  2. Those who enjoy looking after people, but don’t want responsibility.

  3. Those who can’t get any other job.

  The last comment is certainly not meant in a derogatory way. A great many of those in the third group are newly arrived immigrants from middle European countries (the former communist bloc) who need a work permit to stay in the country, and who can get one by signing up to take the NVQ Healthcare at Level 1, and working in a care home. Many of these boys and girls are very good indeed, and I have met them. They are young, bursting with life and happiness, not afraid of hard work or getting their hands dirty. Also, having been brought up in a culture that does not exclude the old from family life, they are gentle and understanding.

  In 2013, it will be mandatory for all newly recruited nurses to have a degree. It will not be possible to enter the nursing profession by any other door. Suddenly it is upon us – health care assistants will be the most significant workforce in hospitals and care homes. At present, it is estimated that there are over 700,000 practising HCAs in the UK, but, as they are not registered or regulated, the number is not really known. Their training has been insufficient, to say the very least, yet they will be the ones who do the basic bedside nursing that is the foundation of nursing care, as anyone who has suffered long-term illness or debility will tell you. It is also, for this reason, the most noble.

  Doctors come and go, but nurses or care assistants are always there. All the high-tech, multi-drug paraphernalia in the world is as nothing beside the human need for human touch and contact – which is what good bedside nursing is all about.

  We can prolong life for decades, and resuscitation is fast becoming the norm, and all these people will have to be looked after. The decisions are made by government think tanks, by teams of professors at the British Medical Association, by ethics committees consisting of philosophers and theologians and senior judges. But having come to their conclusions, and issued their reports, they can walk away from the problem. They don’t have to do the work. The work is left to care assistants, who receive barely a living wage for work that is arduous and demanding, and for whom the strain can sometimes be insupportable.

  We are a rich nation, and like all rich nations we need a subculture of underprivileged people to do the dirty work that we would not want to see our sons and daughters doing. Much of the work of care assistants falls into this category, and they are the ones who will look after us in our old age. It is worth remembering that, when our faculties, our senses, our mobility and our organs fail us, health care assistants will be more important to us, and have far more power over us than doctors.

  Let me end this chapter by reproducing some of the NVQ introductory literature, which can be obtained online. It is addressed to prospective health care assistant candidates at the initial entry level:

  NVQ Care Programme Information Pack

  There are no academic qualifications needed to be a care assistant. All care assistants are expected to undergo a twelve-week induction programme [this is frequently not observed -author’s comment]. Direct experience is not necessarily required for the job, but it is useful to have some experience in working with people. Care Assistants are in high demand and it is relatively easy to get a job. The main employers are social services, hospitals, private or NHS nursing homes and agencies.

  Personal skills: Care Assistants need to have excellent interpersonal skills and the ability to work with all kinds of people in situations which can be stressful or emotionally draining. More specifically they should have:

  A friendly approach and the ability to put clients at ease, whatever their physical or social needs

  The ability to be tactful; and sensitive at all times

  A good sense of humour

  A high level of patience as shifts can be long and often stressful

  Excellent communication skills

  The ability to deal with aggressive or anxious clients

  A certain level of physical strength

  Good stamina

  The ability to stay calm under pressure

  The ability to think quickly and solve problems as they arise.

  Working Conditions: Care Assistants usually work shifts, which means their hours and days of work vary from week to week, and may include night shifts or weekend work. Shifts can be long and demanding, so care assistants need to have good stamina and both physical and emotional endurance.

  The contempt with which this hedonistic society looks upon simple virtues is reflected in the pay reward. We offer care assistants £11,000 a year: that is £5.70 an hour, with no guaranteed sick pay, holiday pay or maternity leave, and no guaranteed pension.

  Would you, the reader, do it? Could you? Would you advise your son or daughter to become a health care assistant?

  Truly, truly, I say to you, when you were young you girded yourself and walked where you would; but when you are old, you will stretch out your hands, and another will gird you, and carry you where you do not wish to go.

  — St John, ch.21, v. 18

  1968

  CONGESTIVE HEART FAILURE

  The year was 1968, and I was night sister of a small provincial hospital. I walked into the ward, and there he was – Dr Conrad Hyem. We recognised each other instantly, though it had been many years since the night in Poplar when we parted. No doubt we had both changed. I was a married woman in my thirties with two children. And he? Well, he was very much changed. He looked frail, sitting up in a hospital bed, breathing with difficulty a bluish tinge around his nose and lips, and an anxious look in his eyes. The ward was quiet after the daytime bustle, and peaceful. A single light glowed above the bed of the frail old man suffering from congestive heart failure. I went over to him, sat on the edge of the bed, and took his hand. He squeezed it, and a crinkle in the corners of his eyes showed his pleasure.

  ‘Jenny Lee,’ he whispered, ‘after all these years … I have not forgotten you. How could I? And now you come to me when I am dying. You are thrice welcome. What a happy chance.’ He sighed with contentment, and squeezed my hand again, such a weak little squeeze. ‘A happy chance.’ He looked up and smiled once more.

  The effort to speak had made him breathless, and he leaned back on the pillows panting, shallow breaths, his nostrils dilated with the effort to take in more air. An oxygen cylinder was beside his bed, and I turned it on and placed the mask over his face. He breathed the life-giving gas for a few minutes, and then pushed it away. I adjusted his pillows, and he leaned back comfortably and closed his eyes. I whispered: ‘I must go round the wards and see my other patients, but I will come back; be assured of that.’ He nodded and smiled and patted my hand. ‘Jenny Lee,’ he whispered, ‘a happy chance.’

  *

  A hospital is a lovely place to work in at night. Staff is reduced to about ten per cent of the number required during the day and there are no routine admissions or discharges, no routine surgery, no moving of patients to special departments for treatment, few telephone calls. All is quiet. I refer here to the general wards of a hospital, and not accident and emergency, where day can blend into night, and night is usually more hectic than day.

  I went quietly around the hospital, taking the night report from each nurse in charge, seeing a patient here or there, checking a drug, adjusting some treatment, mentally noting this or that to be checked on the next night round, and then returned to the male medical ward, where I sat in the office reading Dr Hyem’s notes. Congestive heart failure was the diagnosis. Long-term diabetes, for which condition I had treated him in the first place, had caused generalised atheroma of the arterial circulation (atheroma – from the Greek for ‘porridge’). Just as a plumber may say, ‘Your central heating won’t work because the pipes are all furred up,’ so it is with the circulation. The arteries become conge
sted and the heart, which is the central pump, gets weaker and cannot work properly.

  I paused in my reading to ponder what I knew of his past life, his moral strength, his suffering, his mental anguish, and his heart’s grief at the loss of his wife and children in the Nazi gas chambers. ‘His heart’s grief’ – can the heart grieve, or is it just a pumping mechanism to circulate blood and oxygen throughout the body? Is mankind just a series of reactions to chemical and biological stimuli, or are we more than that? Will we ever know? Perhaps it is better that we can never be sure.

  I continued reading. Dr Hyem had had several warning attacks of angina pectoris, which can best be likened to cramp. It is painful but not fatal. For years he had been inhaling the fumes of amyl nitrite and taking digitalis, which is a very ancient extract of the foxglove plant, known to mediaeval monks, and cultivated in their herb gardens. At the same time, atheroma of the blood vessels caused sluggish blood flow, and his heart’s efficiency was compromised. This led to other problems.

  Oxygen is the key to animal life. If every cell in our bodies does not receive sufficient oxygen, it will die. That is what had been happening to Dr Hyem for several years. Due to lack of oxygen, the functioning of his lungs, kidneys, liver, pancreas – all his organs – was affected and their efficiency seriously diminished. This is the end result of congestive heart failure.

  Eventually, Dr Hyem’s labouring heart could take no more and he had collapsed in a shopping area. An ambulance was called and had brought him to hospital where we were able to treat him. In these days of high biotechnological medicine, the treatment available back then does not seem much – morphine sedation, bed rest and an oxygen tent, amyl nitrite, digitalis, heparin (an early form of clot-buster), mersaryl (an early diuretic). It may seem very little, but it was enough to pull him through, at least temporarily.