The Ugly
Band levels and Coloured Scrubs
Nurses in the National Health System (NHS) start as a band 5 nurse, the entry level for any newly qualified nurse. As you gain experience, you become a band 6 nurse which includes being in charge of the department. Also known as a junior sister. Followed by being the source of all knowledge, a band 7 nurse with managerial duties, a senior sister. On the other side of the spectrum a band 2 health care assistance, is an entry level position which provides direct patient care. And a band 4 which has duties similar to certified nurse’s assistances (CNAs) in the USA. Each band has a different scope of practice and different colour of scrubs.
The visual hierarchy is one of the sources of poor communication, in my personal opinion. The navy blue worn by the senior/junior sisters (nurses) is a status marker and the assumption is that you must know what is going on in any given situation. With my recent change in position, I felt the shift immediately. Previously in sky blue I had to speak up to be addressed. Now in navy I am the first to be addressed in the room, whether I know the patient. The saying goes ‘the paler your blue the least you are heard.’ In addition, the nurses tend to stay within their own tones. With the change in colour I am no longer one of them but part of the management group.
Long queues for ambulances
Two years ago, when I started, I appreciated the ambulances queuing to bring patients to the hospital. An abdominal pain that was stable might have to wait for 4 to 6 hours to get brought in. But recently I have come to see the fault in the system. An elder man who has fallen due to leg weakness (“off legs,” the colloquial term), and who is otherwise stable will have to wait. And what could have been a quick lift assist turns into a long lie, a patient on the floor for four plus hours, and now needs further medical evaluation. The long wait times for ambulances also creates a situation where we get very sick walk ins who realized it was faster to get a friend, family member or taxi to bring them in.
Lack of Support
Newly qualified/graduated nurses have no residency program. After a two-week orientation to the emergency department they are expected to work independently. Six shifts, one day to learn to manage five patients. One day to observe and work in the resuscitation bay. Another day to work ambulatory chairs, sit to fit patients, with a nurse to patient ratio of 1:8. One day to learn to work in pediatrics before you are left to fend by yourself. And if you fail you just may have not been cut out for the job.
I should note that the NHS does have a Preceptorship Program for new nurses which gives them 7.5 hours a month of additional training, out of the department. And in the Emergency Department we try our hardest to support the new nurses.
The Bad
Reproving yourself as a nurse
In the USA you finish nursing school, you take your board exam (the NCLEX) and you are done! But here you graduate and you still have to prove yourself as a nurse. It does not matter if you did it at school you must prove once again you know how to administer medication, calculate drug dosages, draw blood, insert a cannula, do a male catheter, or place a nasogastric tube. And you cannot do any of those tasks until you have documentation that you have completed the training in the hospital.
As a new employee, I had to demonstrate all the competencies stated above when I started here. A standard across most hospitals in the UK. Therefore, as a clinical educator I spend a great of time having people demonstrate their skills to me. It does not matter if you have been a nurse for one month or 10 years.
It can wait.
Whether it be a colonoscopy, knee replacement, or even a wonky gallbladder. If it is not an emergency you will need to wait. Whilst I worked in anaesthetics it shocked me to see the number of weeks (50, 64, 72) next to the patient’s name stating the length of time they had waited for their operation.
The long wait list for treatment is not new. The combination of non-urgent services being suspended during the pandemic and staffing shortages has created a record high of almost 7.21 million people waiting for treatment as of October 2022 according to the British Medical Association.
Pay
I always said I would do this job no matter what the pay and now I stand behind my words. Nurses, along with other healthcare professionals, are not treated as professionals but more blue-collar workers and it is reflected in our wages.
As an experienced nurse, getting the highest level of a Band 5 nurse I get paid gross £16.84 an hour ($20.12). My take home after taxes being £11.75 an hour ($14.16). The funny thing is that cost of living is less here, so it has not affected our way of life too much.
Per the livingcost.org site: The average cost of living in the United Kingdom ($1818) is 18% less expensive than in the United States ($2213). The United Kingdom ranked 16th vs 5th for the United States in the list of the most expensive countries in the world.
The Zebra
“When you hear hoof beats, think horses, not zebras…. But don’t forget about the zebras”. Due to the NHS structure, there is minimal funding for the research, particularly if it is an obscure disease. As the UK government site states “although rare diseases may be individually rare, they are collectively common.”
In 2013, the UK government and the 3 devolved administrations published the first UK Strategy for Rare Diseases (the strategy). This may seem like a good advancement, but it is not. It was a start. It was not until 2013 (the 21st century!) that the first strategy for rare diseases was developed in the UK. A fellow nurse recently got the diagnosis of hyperparathyroidism and all the research she found was from the USA. She is now looking at getting her parathyroid removed sometime next year. Since it is not emergent, for now they are just monitoring her calcium levels and giving her the appropriate treatment if needed.
The Good
The reasons we stay and tolerate the above
Free healthcare…
…Well sort of, we pay into the system via our taxes. But when you go see your primary care physician or the emergency department you do not have to worry about a co-payment. Every month, based on the amount you earn, you pay National Insurance Contributions (NIC). The tax is about 13.25% of your gross wages but if you are a low-income earner the tax is waved.
ALL medication prescriptions are £9.35 each and if you are under 18 years old or over 60 it is free.
But the biggest thing you get with socialized health care is an ease in society. People can choose their profession not for the health care coverage but if they like the job. An artist can be an artist. Small businesses do not have to calculate healthcare cost into their business expenses, giving them a better chance to thrive. Car insurance is MUCH less but not due to good driving but because medical expenses do not need to be calculated into the cost. You do not have to worry about getting sick and being able to afford the hospital bill, that societal worry is gone.
Work Benefits
When I first started working at the NHS I was so busy learning how to maneuver the system that I did not consider time off. Three or so months after I started I got pulled aside and told I needed to take a week or two off. Otherwise, my annual leave would accumulate and it would be difficult to use. Management requested I take at least one week off a quarter. I get seven weeks of paid time off, which is one of the reason we can travel with such ease.
Annual leave is not part of sick leave. You do not have to accumulate your sick leave base on hours worked like in the USA. I do not know if there is a designated number of hours for sick leave. But base on a research you get one month off full pay and the following months at half pay.
Sick leave here also includes mental health, including stress. I do not recall seeing someone take sick leave for mental health concerns back in the USA. You of course need a valid doctor’s note, but there is no limit of the time you can take off. We also have free counselling service through work. In addition to a Staff Wellbeing hub that provides stress management resources such as free online yoga, fitness classes, menopause educational sessions, and holds wellness campaigns.
Yes, I complained about the scrub colors earlier but at the start of your employment you are given your own set of scrubs. I no longer need to purchase them. If your position changes you get a new set. Additionally, if you have wear and tear, they are replaced at no cost to you.
Camaraderie
Being part of the NHS, I am part of a bigger community. People will say “I work in the NHS,” you are not working for them, you are in it, you are part of it. You understand the struggles and the rewards being part of the national health system.
And they support you back.
The cost of living is going up all around us and the NHS is very aware how it affects their employees. My hospital does not shy away from that reality and recently sent an email stating:
“We know such concerns can impact overall wellbeing and happiness, and whilst it’s beyond our control to ‘fix’ the wider cost of living problems, we feel strongly that we should aim to provide the widest range of support possible to our people through this period.”
With the email came a list of reward programs to support us during this time. Including an increase for mileage rates reimbursement for those that drive for work. And the creation of a Hardship Fund for cases of unforeseen financial needs. In addition to discounts specific to NHS employees.
And it is a group you want to be part of. I felt the inclusivity soon after I started working here. The executive team sent email addressing race head on. Below is an excerpt of the email
The week before Christmas we were in a state of critical incident due to high patient volume with a lack of beds. There was physically nowhere to put incoming patients. The seams of the hospital were bursting. All educational and non-urgent meetings were cancelled. Nurses from other wards came to the ED to help with patient care. And the Executive team were walking around with the tea trolley handing out a cuppa (a cup of tea) to patient’s, family members, and staff. Everyone in the hospital came together to help, we were a team.
So even though the NHS has some ugly bits, or bad areas, for me the good outweighs it all.
