Enigmatic, Nick, very enigmatic – care to say more, I mean isn’t this a bit like saying drugs are, err, ‘bad’?

It was wrong then and it is wrong now.

As I’m sure you now know, the understanding of diabetes has moved on a long way from those dark ‘no sugar in his tea’ days, which at this remove seem remarkable (given the extent to which my highly sporty IDD nephews stick away the sugar to avoid going hypo). Those were dark days, relatively speaking.

My piece, as I’ve set out above, was a piece of history, and it’s important to recognise that overall there has been huge progress in the NHS and that staff are much better equipped and trained than they were 35 years ago notwithstanding some of the concerns both I and other commenters above set out about how workforce divisions have led to the marginalisation (and poor staffing ratios) for some staff at the bottom of the pile. Recognising that does not, much as Mark M @5 would love it to, mean that the NHS is rubbish and needs ‘reform’, whatever thay means, but that there are still challenges to overcome for a socialist health service.

But what’s this about docs and nurses having distinguishing clothes and haircuts? I’m intrigued to know what this entails.

Medical students tend to dress in a quite consciously middle class way – button-down shirts, tank tops, short-back-and-sides haircuts for the boys, sensible long hair for the girls. Nursing students tend to dress more casual – jeans, trainers, t-shirts, fashion logos, whatever spiky hairstyle happens to be flavour of the month at Toni and Guys.

This gets a bit blurred once they qualify, as the nurses will be in uniform from then on. That said, I work in psychiatry where we don’t wear uniforms. As you say, psychiatry tends to be more democratic than the rest of healthcare, but even so the medics tend to wear a suit and tie (or, failing that, at least a smart shirt) while the nurses tend to dress as casually as the dress code will allow them to (or, if they’re on night shift and there’s not many managers about, more casually than the dress code says they’re allowed to.)

I once knew a nurse who was on her way to run a parenting class at a child and family clinic, and she got pulled up by the clinical director for wearing jeans. She patiently explained to him that there was research evidence that attenders of parenting classes feel more comfortable if the instructor dresses casually.

She said to me afterwards that she was glad that he didn’t ask to see this research evidence, as then she would have had to make some up.

Thanks for your contributions. As I’ve tried to set out briefly to Lee in my comment back above, but you all set out better, the way class divisions are expressed in the NHS has changed significanlty over the last 25-30 years.

My concern about the ‘degree-ification’ of nursing (and a concern that many of us have held since the 1990s) is that, courtesy of what in some ways is a legitimate aspiration to professionalise nursing, the profession’s bodies (RCN, UKCC-as-was) have sold out the wider body of the NHS workforce. Nowhere is this more strongly evidenced than in the RCN’s mid 2000s’ attempt to ‘define nursing’ (http://www.rcn.org.uk/__data/assets/pdf_file/0008/78569/001998.pdf) where there is an attempt to put clear blue water between the ‘profession’ and those who do much of the actual nursing.

First and foremost, you are right to say that from the way I’ve (necessarily) briefly set out the story it could be interpreted as simple bullying on my part.

There isn’t room in this type of anecdote for much background – that actually we’d already worked together for a while, that we got on reasonably well at a time when there was a cultural shift on the ward towards first name terms between doctors and nurses and a greater level of informality, and that as soon as the brief shouting was done there was a return to calm explanation and agreement on the course of action; I honestly can’t remember whether I offered an explicit ‘sorry I shouted’ but I certainly don’t remember any immediate sense other than that I’d acted urgently (how urgent this was in the context of the actual biomedical situation, we’ll never know, because I couldn’t know how exactly the guy had been in that state). To the best of my knowledge, I genuinely don’t think the doctor felt he had been bullied, but yes what I am suggesting is that over time he felt the legitimacy of his authority had been undermined and, yes, I am suggesting a class-based explanation for the way he reacted over time. That is, as I’ve said, why I remember an otherwise relatively day-to-day incident (an emergency, but not in fact an emergency) very well.

The other key point to make is that this is a story from a quarter of a century ago. The reason I recount it now is because this is the first in a couple of posts planned about the way the expression of class divisions has changed over the last twenty five years. Back then, in a large London teaching hospital, the class distinctions and the way they were acted out on wards up and down the hospital would gobsmack a younger generation. This was still a time when senior medical staff trained in the 1950s would quite happily reduce nurses to tears on the ‘grand tour’, insulting them over anything they considered to be a minor indiscretion in ward administration or even ‘deportment’.

Commenters above are right to point out that nursing has moved a very long way since then in terms of the way its professional status is recognised, with (as noted) senior nurses now involved in medical school training, for example.

What Zarathustra point out above though is entirely correct (and a focus of my second post). This professionalisation of nursing has come at the cost of a new class division between trained nurses and those who actually do the nursing as we once conceptualised it – the Health Care Assistants.

The point therefore of this post, ancedote that it is, is to set out the case that the NHS, even since its creation when the hospital consultants lobbied and won key concessions that allowed them to retain their major priveleges, has been the subject of class (and gender) inequalities, which shift in their expression over time, but which are institutionally designed to divide and rule the workforce overall and now result in a marginalised and exploited workforce of HCA (and cleaners etc.).

I’m interested in your suggestion that my anecdote is ‘baseless’. The base for my anecdote is my own experience, and that is perfectly legitimate. You will see from several commenters above that this experience chimes with that of several others who trained/worked as nurses in the same kind of period, and several of them go on to record (anecdotally) how things have changed since then, especially with the development of a new ‘two tier’ nursing workforce.

Just on a point of detail about who would have taken the rap had I acted without a verbal order then confirmed in writing, and if that had been the wrong decision. That would have been me, and I would have been struck off. It is likely I would, in the 1980s, have been struck off in such circumstances even if it was the right thing to do if the doctor had chosen to report my actions in a way designed to ensure that.

Re class:
when I was training in the early seventies, there was certainly a class difference, but this gradually became blurred. I’ve certainly been attended to by doctors with clear demotic accents. At the end of my working life in an out-of-hours psychiatric emergency team, the professional difference was barely tangible, but then, psychiatry is generally more democraic. But I do think that many nurses now seem to want to model themselves on the characters in TV medical series, see, for instance, Holby City, where the nurses spend most of their time advising doctors where they’ve gone or might go wrong. You’ll see the occasional non-speaking extra in the background doing the menial nursing. But what’s this about docs and nurses having distinguishing clothes and haircuts? I’m intrigued to know what this entails.

Having specialist knowledge and skills doesn’t necessarily justify why nurses should have a degree. My first job, in 1963 was as an apprentice compositor. What’s a compositor? See here:

http://www.localhistory.scit.wlv.ac.uk/Museum/printing/printers/wilkes/wilkes03.htm

This was a highly skilled job entailing specialist knowledge and techniques, requiring a whole 5 years of weekly day release. Doesn’t mean I should have had a Degree in Printing, though. But I did get a lovely document, my indentures, signed off with a sealing-wax stamp at the end though.

Trofim, the issue of student nurse drop-out rates is more complicated than depicted in that Times article.

As the article says, drop-out rates vary wildly between the universities – my university’s drop-out rate was far lower than some of the very high figures mentioned at some unis.

From what I’ve heard on the grapevine, those with the very high levels of drop-outs tend to be those universities who’ve engaged in a mad rush to put bums on seats in order to secure funding, and as a result wind up taking on students who were never really up to it in the first place – and then they promptly drop out because they’re simply not capable. I’d say this is the problem rather than the supposed “elitism” suggested by the Times.

Either way, the pass mark for a nursing student essay, even at degree level, is 40%. If they don’t pass that then they get two attempts at a resubmission before they’re asked to repeat a module. Anyone who doesn’t have the intellect to achieve this shouldn’t have peoples’ lives in their hands, quite frankly.

The main reasons for drop-outs on my nursing course were financial, especially for mature students trying to juggle a family and a mortgage. Behind that was people who dropped out due to illness or pregnancy. Academic standards came behind those other issues.

I think you’re probably right that other issues such as personal pride may be involved as well as/instead of things like social class and professional turf.

Is there a class divide between doctors and nurses? I don’t doubt it. This is a bit of a generalisation, but if you go into the canteen of a medical school you’ll be able to easily distinguish the medical students and the nursing students by the differences in clothing, haircuts and accents.

Though before nurses get into too much inverse class snobbery, it’s important to remember that the same issues of class and professionalism exist between between nurses and healthcare assistants. Many a newly-qualified staff nurse will have had a similarly chastening experience at the hands of an experienced HCA. I know I did.

If this did happen, Lee (although that is not the sense I got from the anecdote) it is only because Paul was aware that untreated hypoglycemia leads to brain damage, and therefore felt compelled to put the interests of the patient above all else?
http://stroke.ahajournals.org/cgi/content/abstract/17/4/699

In a perfect world adequate medical support would be available for junior doctors but there are ALWAYS instances when the experience of a nurse is required as well.
I think this pattern is unlikely to change (in hospitals) for x2 reasons;
*increasing ‘specialisation’ – this had led some to accuse hospital doctors of being ‘partialists’ because they only look after the kidney, eyes, or gut, say, rather than the global medical needs of the patient (the consultant pathway is now set only 2 years after qualifying).
*NuLab have validated roles that nurses have ALWAYS provided informally (see 8).

The media is awash with stories of doctors who came a cropper after ignoring the advice of nurses and it has been suggested that these poor decisions MAY have been linked to some of the power games that Paul alludes to?
http://www.independent.co.uk/life-style/health-and-families/health-news/doctor-guilty-of-killing-intensive-care-patient-1548027.html

http://www.bio-medicine.org/medicine-news/Sheer-exhaustion-makes-a-junior-doc-u2019-kill-a-patient-21-13495-1/

http://www.dailyecho.co.uk/news/4326945.Woman__87__choked_to_death_after_doctor_gave_her_pills_despite_warning/

I certainly accept your points about the importance of communication but I will leave you with this final thought – one of the perennial criticisms leveled at doctors is that they do not always LISTEN and because they don’t listen sometimes bad things happen.

My hypothesis is that doctors regard themselves (as a profession) as the brightest of the bright and come to believe that they simply know best – in the majority of cases I’m sure they do know best but every now and again a catastrophe arises because they are guilty of poor communication.

This was certainly the case when a relative of mine died – his parents knew the initial diagnosis simply did not stack up (and tried to communicate this) but several members of the medical team did not listen, or ignored concerns until it was too late.
Maybe if a ‘brick shithouse’ like Paul had been batting for them things might, I repeat MIGHT, have turned out differently?
http://www.bio-medicine.org/medicine-news/-u2018Drunk-u2019-Doctors-Misdiagnosis-Proves-Fatl-19455-1/

After discussing this post and reading it again the only thing I can take away from it is this:

A nurse effectively bullied a doctor in to making a decision they had no information about. I’m not suggesting here that in the situation the nurse did not know it was the right course of action, but the nurse had not explained why the decision was needed to be such until AFTER administration. A doctor was being forced to take the word of nurse they did not know nor knew they could trust, and it’s supposed to be purely a class or experience thing that explains the uncertainty they had?

If the order had been the wrong one to give who would face the consequences? The doctor.

And we’re all just supposed to buy that the reason that the guy was “off” after that was a fear of losing hierarchical control and being intimidated by a “brick shit house”? Has anyone asked the doctor why he was more formal after that? Couldn’t at all be that a big bloke completely made an arse out of him and his pride was hurt and that he is embarrassed…breaking down in this case the ability to form an informal relationship immediately or in the long term? Just as viable a situation but perhaps not in tune with the story that we all want to hear?

If I got shouted at by anyone in my first week of work it would take a hell of a long time for me to get on to anything other than strictly professional terms with them unless they came and apologised. Paul, did you ever apologise for the manner in which you may have addressed him in the heat of the moment? Did you ever try to break down the class divides you hate so much? I’m hoping you did and that there is more to this story.

As for the reactions of Mel Phillips et al towards nurses having degrees, I’m a degree nurse (passed with first class honours) and I’ve always gone to great lengths to ensure I’m not too posh to wash/too clever to care/insert Daily Mail slogan of the day here. Quite frankly, if I swanned onto the ward acting like I’m above piddling things like hands-on care, then the HCAs would have me for breakfast.

There are many problems with nursing care at the moment (abysmal nurse: patient ratios on NHS wards, reams of paperwork landing on our desks, a global shortage of nurses, greater concentrations of older and sicker patients on the wards due to an ageing population etc, etc) but nurses having degrees is not one of those problems.

http://www.timesonline.co.uk/tol/life_and_style/health/article6920871.ece

If we look at trends over the last 50 years we see more and more oldies being placed into institutional settings, increasing numbers of children in ‘day care’, while fewer and fewer people die at home (now just 18% of the population).
http://www.gsttcharity.org.uk/pdfs/gomes.pdf

No it doesn’t, the 2 year State Enrolled course (which was practical based and very limited, academically and promotion wise) was phased out with project 2000 c. 1992. The 3 year Registered Nurse course has always been the mainstay of professional nursing.

Registered Nurse Spider.

Personally I doubt if the original architects of the NHS would even begin to recognise today’s £100billion beast which now provides services for organ transplantation, fertility treatment, gender re-assignment, HIV, etc (not to mention the anxious army of of swine flu neurotics or ambulance callers).

The role of the nurse has certainly changed dramatically from those ‘Carry On Doctor’ days.

Nurses now prescribe independently
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4133743
And are being pushed into pseudo-medical roles – the so called ‘noctor’ or ‘quacktitioner’
http://www.nmc-uk.org/aArticle.aspx?ArticleID=82
Nowadays nurses even teach clinical skills and personal development in medical school.
http://linkinghub.elsevier.com/retrieve/pii/S1471595303000362

In fact a long running debate has raged across the medical blogs for several years with many respected docs (and indeed nurses) claiming NuLab have been responsible for ‘dumbing down’ health – others claim that these (nursing) developments have been long overdue, and have merely maximised potentials within the largest sector of the clinical workforce?

As you know this subject has kicked off again with the news that nursing is to become a graduate only profession – even the irrepressible Melanie Phillips has felt compelled to make a pronouncement on the matter (sniggers).
http://www.spectator.co.uk/melaniephillips/5532246/nightingale-must-be-turning-in-her-grave.thtml
Doctors may boast a higher quota of toffs but the ‘genie’ seems to be well and truly out of the nursing-lamp.

So yes, I suspect a new type of nurse IS already emerging, but the profession’s inherent conservatism (with a small c) still tends to baulk from the political issues you have raised.