Contribution to 2020health’s recent report ‘Too posh to wash? Reflections on the future of nursing’
By Rosemary Macalister-Smith RGN, RM, ADM, BA (Hons), MSC, LLB (Hons), LLM Healthcare Advisor (nursing, midwifery and regulation), Healthfit (Supported by; Esther McFarlane RMN, BA Ed Studies, PG Dip Nurse Education, RNT, RCNT, Healthcare Advisor (mental health and education), Healthfit)
The Nursing and Midwifery Council Code of Conduct states; “Make the care of people your first concern, (by) treating them as individuals and respecting their dignity; respect people’s confidentiality; collaborate with those in your care; provide a high standard of practice and care at all times; be open and honest, act with integrity and uphold the reputation of your profession”.
When considering good nursing care a ‘vox pop’ conducted in November 2011 identified that; “Nurses should treat all their patients with kindness, honesty, respect, dignity, an understanding of their vulnerability and quiet confidence”. When asked what was the singular most important feature of nursing care the overwhelming response was “the patient should be understood and treated as a person, not as a disease”.
There is a growing body of evidence that suggests that these aspirations are not being reached which raises the questions ‘why’ and ‘could’ and/or ‘should’ it be fixed. There has been no specific paradigm shift that has lead to this position but there has been creeping change over several years. The change of nurse education to a university knowledge-base system, the loss of direction over who is responsible for direct patient care and the lack of value placed in leadership over management.
The move of nurse education from the hospital-based apprenticeship model to the university-based student model, and now from diploma to degree has caused much debate. Under the apprenticeship model the emphasis of nurse training was on gaining experience, learning the craft of nursing, under the guidance of a skilled supervisor. The gaining of knowledge was important but secondary. The understanding of ‘why’ was not necessary for a nurse so long as she/he could ‘do’.
The move to academic-based education shifted the emphasis from experience alone to a more informed knowledge-based approach. Some have argued that this was a period of the acquisition of knowledge for knowledge’s sake and that there was insufficient integration of knowledge to fundamental nursing care creating the ‘theory-practice gap’.
In gaining knowledge the nursing profession has lost focus on gaining the skill of caring.4 They have underestimated the importance of this skill to the patient and its impact on the patient’s quality of life. What used to be considered fundamental nursing care such as, getting to know the patient, working with them and their family to minimise the effect of illness, is no longer considered important in the rush for the acquisition of knowledge. If nursing is to be the autonomous profession described by the World Health Organisation5 then improved patient care must first be achieved.
Following a degree level qualification it should be expected that the care of the patient is delivered as degree-level care. Commentators on degree-level programmes write of “the inclusion of aspects of cognitive learning which relate overall to the development of cognitive abilities’ and ‘the intended outcome is to produce a critical, autonomous professional, able to respond flexibly to different situations and capable of problem solving and addressing complex issues” (Miller et al, 1994). These are probably accurate aspirations but as a route to understanding, valuing and achieving excellence in the skill of caring they are falling considerably short.
Fears that nursing would be diminished as a therapeutic endeavour if the hands-on role were to be relinquished are often voiced. Such fears have been fuelled by the increasing role of the support worker taking on many of the tasks previously thought to be the domain of the qualified nurse; the qualified nurse having moved into taking over roles previously the domain of doctors. It is curious, perhaps, that the profession and others should believe that care has to be reclaimed by qualified nurses since there is little evidence that care was ever delivered exclusively by qualified nurses. There really never has been a ‘golden era’ of nursing care. Studies (Davies, 1992) of nursing activity in units providing care for elderly people persistently reveal that the majority of direct care has been provided by ‘nursing auxiliaries’.
However, this misses the point. Patients suffering physical or mental illness are saying that they want to be cared for in such a way as preserves their dignity, respects them as human beings, not simply a disease, and keeps their basic human needs provided for, such as adequate diet, adequate fluid balance, warmth and comfort. If this is the perspective of the patient then, clearly, this is not being achieved, whatever the profession may argue. The time has come for all those involved in healthcare to understand that patient care is not good enough and that devolving the skill of care giving to an unqualified and insufficiently supervised workforce is not working. All patients are given a medical diagnosis but a nursing diagnosis which identifies the way that the illness affects the person and their lifestyle and goes on to prescribe ways to minimise the effects of the disease or ameliorate them and who should provide this care may help. However, it must be recognised that this is not simply a nursing problem but that the answer lies within the whole system.
Over the past 50 years the leadership in nursing has been undermined and diminished. This may or may not have had an impact on the standard of care giving. In 1998 Alan Milburn (Secretary of State for Health) announced he was reintroducing the matron to ensure that the patients received the care they needed. His plan, of a senior level nurse free to visit clinical areas to provide support and to address local shortcomings, has not been a resounding success. The ward manager /sister should have detailed knowledge of every patient at their finger tips, she/he should know the nursing staff and medical staff sufficiently well that those who need more support are not left exposed and the patient care is constantly at the heart of ward activity.
Trust Boards have a substantial role to play in ensuring good care giving. The leadership provided by the Board should engender a total commitment to the primacy of good care. Although there are Nurse Directors on all Trust Boards few lead detailed discussions about patient care and a real understanding by boards of the impact of budget management and achievement of targets to improving the patient condition? Nurse Directors are in a position to visit clinical areas every day and to keep their directors colleagues fully informed of the quality of the activity. It should be a matter of good corporate governance for boards to understand the experience of the patients in their care. Evidence from Mid Staffs, Maidstone and Tunbridge Wells, and High Wycombe and Stoke Mandeville and others; demonstrate the failure of Trust Boards to be informed of, and to take appropriate action on, good patient care. In saying that ‘The fish rots from the head’ Bob Garrett (1996) explained that when an organisation fails it is the leadership that is the root cause.
Nursing is one of those occupations that seldom call for clarification. From little girls with career aspirations to politicians legislating for healthcare they all intuitively ‘know’ what nursing is. Sadly such intuitive ‘knowledge’ is found wanting. ‘Is nursing working’ is a good question if one is sure what nursing is. In order to value and provide skilled care nurse education needs to understand and be committed to preparing nurses to provide skilled care; the performance of the skill of caring should be in the hands of those appropriately educated to provide it; and the organisational, professional and national leadership must have at its heart a total commitment to skilled patient care.
Miller et al, 1994, ‘The current teaching provision of individual learning styles of students on pre-registration programmes in adult nursing’. ENB, London
Davies S.M, 1992, Consequences of the division of nursing labour for elderly patients in a continuing care setting. Journal of Advance Nursing.