Get up to speed with issues in nursing with The Independent’s series

The Independent has been running an in-depth series on the ‘crisis in nursing’, by Christina Patterson. It’s a useful read if you want to understand how the profession and the wider NHS have changed through the 20th and 21st centuries, as well as how to tackle a big subject from various angles (historical perspective; case study; personal experiences; training; culture).

Links and key passages with contacts and reports in bold below:

Part 1: A crisis in nursing: Six operations, six stays in hospital – and six first-hand experiences of the care that doesn’t care enough

“There were a lot of emails from retired nurses. Jennifer, who spent three months in hospital after a car crash, was “shocked by the attitude of the nurses” and “left with a sense of grieving” about her profession. Maggie said she felt “angry” and “ashamed”. Sheila “despaired” of the “present situation in nursing”. Margaret said that she, and many of her peers, were ashamed to admit they were nurses because of “the reputation of too many unkind, selfish, disinterested and uncaring people” who should “never bear the title” of a nurse. Alison said that she had started to assess the wards her elderly mother was put on for their “level of cruelty”.”

Part 1 continued: More nurses, better paid than ever – so why are standards going down?

“”Certain themes run through all the major reports,” [Professor of Nursing Policy at the Florence Nightingale School of Nursing and Midwifery, Anne Marie Rafferty] told me, when we met last year. “A need to be freed up from the task of domesticity, not to be a skivvy, and not to be a thoughtless responder to doctor’s orders.” As far back as 1964, she said, there were attempts, in things like the Platt Report on nursing education, to “give due recognition” to nurses’ clinical skills.

“The result of these reports, and reforms, and changes in medicine, and changes in training, and changes in society, is that nursing has changed. Frontline Care, a report commissioned by Gordon Brown, which Rafferty contributed to, presents an almost Utopian vision. Nurses, it says, “will work as clinicians, managers, leaders, teachers, researchers, scholars and policy-makers”. They will “encourage and embed innovation”, “expand the profession’s evidence base”, and “act as green champions”. A “new story of nursing is needed”, it says, “to demonstrate that nurses are not poorly educated handmaidens to doctors”. Nursing, it says, “will be perceived as a profession that offers worthwhile, engaging careers with high levels of responsibility and autonomy”.

“Which all sounds very exciting, if you’re a nurse. If you’re a patient, or what the report calls a “service user”, you might be less concerned with “green champions” and more concerned with care. And it’s the quality of nursing care, not the quality of the qualifications, that seems to be at issue.”

Part 2: Reforms in the 1990s were supposed to make nursing care better. Instead, there’s a widely shared sense that this was how today’s compassion deficit began. How did we come to this?

Paul Goddard, a retired NHS consultant radiologist says, in his book The History of Medicine, Money and Politics, that he has “personally overheard nurses moaning that they are fully trained medical scientists and should not be expected to deal with patient needs such as bedpans”. From “day one”, he told me, “nursing lecturers tell the student nurses that they are not the handmaidens of the patients or doctors, but that they are equal professionals”. And then, he said, “when they find themselves on the wards, they’re surprised to discover that nobody cares about their scientific pretensions”. This, he said, “is a bitter pill to swallow”.

“It wouldn’t be fair to say that Project 2000 has produced nurses who are “too posh to wash”, or that their training is all about theory, and not practice. Trainee nurses do spend about half their training time on the wards, but they are supervised by “mentors” who are often too busy doing paperwork to help them turn theory into practice.

“…When Project 2000 [“a new system introduced in the early 1990s, which moved the training of nurses out of hospitals and into universities”] was introduced, the system of State Enrolled Nurses, to support the State Registered Nurses, was also abolished. The SENs, who had two years training, were replaced by healthcare assistants who aren’t registered, or even formally trained. Even after my six stays in hospital, and after talking to scores of people who work in the NHS, I’m not at all sure how this system is supposed to work. I certainly didn’t realise that some of the people who were meant to be looking after me may have had no training at all. It wasn’t clear who, if anyone, was supposed to make sure that patients were fed, or washed. And if it wasn’t clear to me, it probably wasn’t all that clear to anyone else.”

Part 3: How can a profession whose raison d’être is caring attract so much criticism for its perceived callousness? Does nursing need to be managed differently? Or is the answer to develop a new culture of compassion?

Audrey Emerton, a cross-bencher in the House of Lords who qualified as a nurse in the 1950s, has lived through more scandals in nursing care than she can remember. “All of them,” she told me, “came up with the same findings in the end. Last year,” she said, “I went back to look at the 30 recommendations to see what was common to all of them, and it came to me that it was culture.”

Culture isn’t something you change overnight, but plenty of people are trying. Jocelyn Cornwell, at the King’s Fund, has started a programme called Point of Care … Aidan Halligan, a former deputy chief medical officer for England who’s now director of education at University College London Hospitals, says that “culture management” is as important as “performance management”. He has developed a “learning hospital” on the site …  Andy Bradley, a former care assistant … has, he told me, started an organisation called frameworks4change, which aims to put compassion “at the heart of the nurse/patient relationship”.”

Part 4: The nurses who taught an ailing hospital how to care

“[Manchester Royal Infirmary‘s] infection control, which used to be “the absolute pits”, is now used as a model for other hospitals. They’re the best-performing trust for colorectal cancer. Four days before my visit, they were assessed by the NHS Litigation Authority, and were awarded a level 3, which is “exceptional”. And when the Care Quality Commission visited last year, they gave such a glowing assessment that [Gill] Heaton actually asked them if they were sure they were that good. The answer, apparently, was yes. “They said the thing that really strikes us about here is the quality, the care, and the consistency of delivery, but also that staff are really happy.”

“Ten years ago, according to Heaton, there was “no consistency, no structure, and no oversight”. So she set about putting all these things in place. Nurses who weren’t doing their jobs well were moved into “more appropriate roles”. Others were encouraged to leave. Heaton restored the nursing structure, so that there was “a clear line of accountability”. She also set about making sure that everybody was clear what the management expected. “There is”, she said, “an absolute flaw in making an assumption that people know what they’re doing, and that they’re doing their job, and that they’re doing it well.””

And other parts: