Uniform values

After a year as director of nursing, I felt there was quite a lot about the trust I had not picked up.

As a nurse sitting at board level, being able to draw on recent clinical experience is very powerful.

So I decided to go back to the coalface.

Over four months I have undertaken seven clinical day placements working as an auxiliary nurse in the trust. Before embarking on this, I spoke to the rest of the executive team and senior nurses in the units where I wanted to go. Their reactions were satisfyingly positive. I worked in medicine, surgery and accident and emergency.

It is vital not to get in anyone's way in clinical areas, and that includes not giving the impression that you are to be deferred to for any clinical decision.

The choice of auxiliary uniform was ideal for me.

Just by putting it on you become invisible to many colleagues who, in general, would pay a lot of attention to the director of nursing. Doctors, in particular, passed right by.

Some looked alarmed at the over-familiar way in which I greeted them (or perturbed to be addressed at all).

It showed how we use uniforms as a shorthand way of sorting the environment. In general, unless someone has been incontinent, auxiliary staff do not get noticed by some staff.

I also discovered that portering staff would smile and acknowledge me: they didn't when I was in my normal office clothes.

Maybe I just looked funny. Although the trouser suit is more comfortable and sensible for working than dresses ever were, it was embarrassing that, like many middle-aged women, I do not have a waist.

The darts in the tunic were all wrong and I found myself wearing one four sizes larger than my usual dress size in order to breathe.

Undergoing the pre-employment screening that all recruits, bank nurses and students have to go through may tell you more about the process than any report or protocol.Mine uncovered something I needed to discuss with my GP. I discovered how inconvenient that can be if you have a full-time job in a place some distance from the GP practice near your home. If we are serious about getting people to come to work for us, we have to make getting into the job less like an obstacle course.

I failed to get a moving and handling update in before the start date for my placement.Yet, during the placements, the only times that I absolutely had to step out of the role of auxiliary was to intervene over inappropriate moving and handling procedures. In one case, I got new equipment that fellow auxiliaries did not know was available.

There were things that nurses felt they were not allowed to do, or refused to do, for reasons that I could not understand. The auxiliaries seemed particularly disempowered.

There was a process whereby the sister and the managers of the areas decided where they would place me. There is much to learn from the places people decide to show you, and how they respond to you being there. At most, it was an hour into any shift before work took over and people stopped being self-conscious around a manager.

But some places felt much more comfortable to be in than others. I am sure my level of comfort was always directly related to the way staff felt about their workplace.

What shocked me most was the fabric of the hospitals. I had seen the baths before, but actually putting patients in them felt different. And the pace has definitely quickened.When I was last a ward sister in 1986 we had three categories of patient: really sick, getting better, and helping with the tea.

Now all but the really sick are already at home. A 36-bed ward may have 20 discharges and admissions in a single day. And junior doctors do not seem to establish the relationships with ward sisters and nurses that they used to.

So what was learned? Raising your profile is not good in itself, but it gives opportunities to shape and influence nursing and other aspects of care.

do not overdo it. This is to preserve your sense of wonderment at what goes on.When I started my training, a long time ago, in psychiatry, we were told to keep a clinical diary for three months.

The diary was not read again until the end of training. I can still remember the shame of re-reading it. Things that had once shocked me seemed commonplace and normal. I had been socialised into nursing.

As an executive, you need distance to get a feel for what is going on.You need to be able to be shocked or amazed at what is happening in your own organisation. If you are comfortable with it, and you do not plan to retire this year, you are in trouble.

I am now much more focused on how I am going to spend the nurse education budget - on leadership training for nurses in charge and training in empowerment for auxiliaries.

As a director on a clinical placement, you will find there are things that could be done within the resources that are available, but of which middle managers are unaware. It is very important not to come in like a fairy godmother, spreading gifts. The big deal is to make sure managers have the information they need, so they can do that themselves. The success should belong to them.

When you spot things that are not as they should be, you must resist the temptation to tell everyone right away. Telling people off only really works if you plan to be there a lot, regularly: it is not your job.

I saw examples of nursing care and teaching that were brilliant, and better than could be expected in the environment in which the care was being given.

I also saw examples of poor communication and problems with paperwork, hygiene and drug administration. Every hospital has this, but seeing for yourself how and when it happens is very important.

Clinical placements are not inspections and you must judge very carefully what you do with what you see and hear. In general, I only worked for the first part of a shift and then took the chance to talk through the experience with the nurse in charge, to explore ideas and share views of what the clinical area was like from their point of view. It is more important to respond to what is good and make sure people know that you have noticed.Nurses are often very aware of the shortcomings of their own clinical area: you have to stop them from beating themselves up.

You will see things that make your hair curl. Try to avoid thinking of how things were in your day. It is a mark of age, not professionalism, to object to some of the changes that may have taken place.

More seriously, I saw at first hand how some of our cherished policies and risk management strategies pan out in real life. If someone asks you about clinical governance in your trust, as a board member you can point to policies. It can be very different lower down the organisation.

It was slightly unnerving to explain to co-workers in the tea break what the director of nursing was, and that I was she. Recently at a nursing conference I heard a director of nursing confess that many of her nurses wouldn't know who she was. A union leader was disgusted at this, and scandalised that it could be said in public. But the success of the nursing in your organisation does not depend on every nurse knowing who you are. The success is in the outcomes for patients, and that is what this direct experience is about. If you haven't tried it yet, you must. And if I had the stamina of a 21-year-old, I would like to go back to the wards.