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Does the Francis Report offer a New Paradigm for Nursing?

March 4, 2013

It’s ironic, isn’t it? Just as nursing stands on the cusp of achieving its cherished ambition of becoming an all-graduate entry-level profession, the big fat party-pooping Francis Report has plonked itself down in our midst and reminded us in the bluntest possible terms of just why such recognition has been so long coming: in a nutshell, we still don’t know what nursing is.

Underlying all those parts of the Francis Report that relate to nursing is a call for a re-prioritizing of care and compassion. The fact that it has been left to Robert Francis QC, a barrister with no training in health-related professions, to point out how deep the rot has (apparently) gone in nursing is deeply shaming; the fact that it has to pointed out at all – by anyone – is yet another testament, if another were needed, to nursing’s continuing inability to conceptualise what it does and how it does it.

This void at the centre of nursing has been well-documented for the last twenty years at least (1), and the reasons for its existence have been persuasively elaborated, in particular by feminist commentators. The professional ethic, so idealised in recent years by nurse leaders, is, these authors argue, nothing more than a technique deployed by men to protect their own interests and exclude anything which is inimical to them. Caring, according to traditional patriarchal logic, is simply an expression of ‘natural’ female behaviour and by extension is something that ‘anyone can do’; therefore it is ineligible for inclusion within a professional pantheon which privileges specialist knowledge hard won through years of intellectual application and scientific endeavour.

This tension – the purported ‘naturalness’ of female caring behaviour versus the professionalising impulse to claim ‘special’ knowledge – lies at the heart of nursing’s confusion about what it is supposed to be. As a result, practising nurses don’t know which way they are meant to face and despairing of a resolution, all-too-often retreat into paperwork and management; feminist commentators meanwhile have questioned whether a status defined almost entirely by male values is a desirable goal for nursing at all, but have not always presented realistic alternatives. The Francis Report has, if anything, thrown these tensions into even sharper focus.

In this context, the recommendations at the end of the Francis Report make illuminating reading, in particular the distinctions they make between nursing and medicine. As they relate to doctors, these recommendations deal almost exclusively with the provision and monitoring of an appropriate environment for medical training. The contrast with nursing is stark: nurses, Francis says, need nothing less than a root-and-branch re-configuration of their whole culture. The key to this, we are told, lies in selecting nursing students on the basis of their moral values. In particular, and in a statement that drags us headlong back to the ‘good-woman-good-nurse’ ideology of the nineteenth century, Francis says that potential recruits should demonstrate an ‘ability and motivation to enable them to put the welfare of others above their own interests‘ (recommendation 185; my italics).

What is striking is that no such strictures are placed on those contemplating a career in medicine. This is despite the report’s acknowledgement that medical trainees consistently failed to raise concerns about poor standards of care in the A&E Department at Stafford Hospital and that their failure was explained by their supervisor as a reluctance ‘to come out and criticise training, and this is a universal problem because often trainees are not convinced that the survey is anonymous and they worry it will have an impact on their future career‘ (Ch 18, para 184).

This is a truly shocking observation because beneath its outward casualness is revealed the very thing Francis most deplores: a bona fide culture of putting professional interests above those of patients. And yet there is no attempt to censure. Instead, Francis lets medicine off the hook: in the case of medical students, he considers it ‘possible’ that none of them witnessed anything untoward while on placement at Stafford (Ch 18, para 116). Given that conditions throughout the hospital during the period under scrutiny are repeatedly described as ‘appalling’ and ‘dreadful’, this seems barely credible.

So, does the Francis Report offer a new paradigm for nursing? Hardly. You might even argue that it sets us back a hundred years. Writing in The Guardian a few days after it was published, Roy Lilley criticised it for being ‘crippled by complexity’ and ‘mired in detail’ – attributes which he ascribes to its origins in the forensic mind of a lawyer. But for nurses, the problem goes deeper: what Francis has given us is not just something written by a lawyer, but something written by a professional, with a professional’s disdain for mere ‘occupations’. Inherent in his emphasis on the distinctions between nursing and ‘the professions’ and his implied assessment of nursing as something that certain (female) individuals can ‘just do’ lurks the inevitable conclusion that for them, intellectual rigour is not really necessary. In fact, nothing could be further from the truth.

In the immediate aftermath of the Francis Report, nursing’s response has been a mixture of shock, condemnation, contrition and robust avowals that it will never happen again. Whilst this is understandable and necessary in the short-term, in the longer term a more dispassionate stance will be required. The most fitting tribute that nursing as a whole could pay to those who suffered at Stafford Hospital would be a new commitment not to selecting recruits on the basis of outdated sexist stereotypes, but to an intellectual engagement with the philosophy of caring at all levels: from undergraduate courses to leadership formation. Nursing and – crucially – the pubic are best-served by self-confident practitioners, secure in their knowledge base and well-able to articulate it. A deferential, downtrodden workforce – ever-available for everyone else’s dirty work – is the last thing we need. If the lessons of Mid-Staffordshire teach us anything, surely they teach us this.

(1) See for example Davies, Celia (1995) Gender and the Professional Predicament in Nursing; Buckingham; Open University Press.

Francis, R (2013): Report of the Mid Staffordshire Foundation Trust Public Enquiry; London; The Stationary Office.

Lilley, Roy: How Do We Fix The NHS? Ask Frontline Staff; The Guardian Professional; 13-02-2013.

For a very interesting (and slightly different) nursing view of the Francis Report, see

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