Changing times, changing expectations

A contribution to 2020health’s recent report ‘Too posh to wash? Reflections on the future of Nursing.’

By Monica Fletcher, Chief Nurse, Education for Health, The Athenaeum

 

No self-respecting individual will get up in the morning and go to work to have an intentionally ‘bad day at the office’ be they a lawyer, teacher, banker (even!) or a doctor, and nurses are no different. Most people strive to do a good, if not an excellent job whatever their role. Yet if we were to believe the media headlines and general negativity reported in the press, one might be led to believe that modern day nurses are somehow different to everyone else and have some perverted pleasure in being, cold, callous and uncaring towards their patients and relatives. I simply do not believe this is true. So what is happening to the much maligned profession?

Firstly, the context in which nursing is delivered has changed, almost beyond recognition, and I do not think it is useful for ‘mature nurses’ like me, or commissioners or managers or politicians, to hark back (with misplaced sentiment) to the good old days and to ‘how much better it used to be only a decade or two ago’.

So what is happening? Well, firstly I believe society as a whole has become less caring, maybe not intentionally, but due the fast pace and the ‘here and now’ culture. Neighbourliness no longer seems to exist and individual priorities seem to have changed with the priority being self rather than community. I recently had to stand on a train journey from London to Bicester, nothing unusual many commuters would say, but I was in a plaster cast, on crutches, following surgery and not a soul offered to give up a seat. We are talking about basic care and respect for each other as human beings. Have our expectations of how we expect to be treated and therefore how we treat others changed? Maybe we have too high expectations of nurses? The public expect nurses to behave in a way that no longer reflects the values of society itself. Possibly relatives no longer look after their own families as they once did but expect ‘the services’ to do it for them, and because of their guilt they are quicker to criticise nurses and behave with hostility when things go wrong.

Are low expectations of nursing care a self-fulfilling prophesy? So rather than believing nurses will be kind and considerate, are patients and relatives now expecting to have a poor experience in hospital, and as a result that is what they end up receiving. Do nurse lack self-efficacy and belief that they can now strive to offer excellence? We need to reflect on how different the world in hospital now is. The case mix of patients who inhabit our hospital beds has changed beyond recognition, as has how they are managed. Those admitted with medical conditions – tend to have long term problems and mixed pathology; they are generally cared for by specialist medical teams; they are much sicker (as primary care services have absorbed more and more and have pressure to keep patients out of hospital), they are older (as we all live longer), and many experience psycho-social issues. Surgical patients are ‘in and out’ of hospital as quickly as possible, with the pressures on the NHS to improve efficiency. Hence rehabilitation occurs at home; many are admitted as day cases and most are discharged within 2-3 days. Long gone are the days when patients stayed in hospital until their sutures were removed and they were up on their feet. The drive to discharge patients within as short a time as possible means throughput has increased and therefore the demands on nurses has also increased. The luxury of caring for patients who were able to walk around the ward and indeed could help by serving tea to other patients in the ‘dayroom’ nowadays seems like ‘dream world’. As soon as patients can ‘walk’ they are whisked away to discharge units and their beds are filled!

Many so called failures by nurses are reported to be systems failures or situational issues; nurses don’t mean to starve or neglect the patients, they don’t mean to be rude or not communicate with their patients, they are just too busy to spend time on the basics. Be that because of staff shortages, lack of continuity of care, increasingly high demand patients with complex needs, greater technology or more complex procedures for nurses to deal with.

Increased technology may be hampering basic nursing, it may be that there a trade-off between the technological approaches to nursing and old fashioned caring. The question needs to be asked however in the ‘old days’ how many seriously ill or deteriorating patients were missed

whilst nurses were making tea and toast and having a chat elsewhere on the ward. The challenge is to maintain the growth of technical skills and still be able to care. With all these demands on nurses, at the same time we send relatives away at the very time that we need their help to care – mealtimes! Families are deemed a nuisance which makes them suspicious and more questioning about the care. They need to be part of the care supported by nurses and for goodness sake, they mustn’t be early for visiting or bringing in flowers!

My formative years as a student nurse were spent under what I then thought was the tyranny of a ‘ward sister’ who ruled the ward with a rod of iron: god forbid if our patients weren’t out of bed for breakfast and their beds weren’t made before doctors starting coming onto the ward (no laissez-faire patient choice). What about the ‘hospital corners’ or the bed wheels being out of alignment? At the time, much of this seemed futile, but those role models were some of the best and most

professional nurses I have ever known. Little did we know at the time that we were not just making beds, we were observing and talking to our patients and more importantly developing relationships with them, spending ‘hidden’ quality time with them. As a junior nurse I learnt so much, working alongside experienced colleagues as we undertook our duties together. However, now so much of the basic bedside care is undertaken by health care assistants, where is the bedside nursing leadership, our role models? Sadly many of them are no longer directly caring

for patients; they are managing the ward and sorting out systems, sitting in meetings or indeed dealing with complaints from relatives about the care on their wards!

Nurses were once very low down in the hierarchy of health care professionals and have over the years striven for recognition. The profession has fought a battle for academic recognition moving from certificate, degree to master level education. What has this done to the expectations about nurses from patients, doctors and by us, as a profession? I do not believe it is because nurses enter wards with degree level training that they are too educated to care, they just have competing demands and expectations from everyone as a result.

Much of the recent criticism of the nursing profession has emerged from care delivered in institutions, predominately secondary care and care homes. Secondary care nurses are in particular much more exposed to the spiralling litigious culture which pervades the NHS Community and primary care nurses seem so far to have escaped the barrage of complaints and criticisms, possibly patients are less likely to complain in their own homes or when they are ambulatory or it could be postulated that this reflects the different focus of the range of scenarios with the latter groups, or that nurses have more time for the personal care outside institutions.

Courtesy and respect is what most of us want and expect from our fellow human beings and when we are feeling unwell or incapacitated we are even more vulnerable. I find it too hard to swallow that the care has gone out of nursing. As someone who trained as a nurse and has kept

the ‘nurse within me’ throughout my multifaceted career, and in my personal life, I believe caring is what nursing is all about. It is not something you ‘just do at work’ it is a way of life and we may have to work much harder at getting this ethos back into our lives as well as into nursing or it may be that this has been lost forever.