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Does the Francis Report signal the revival of the Named Nurse?

March 4, 2013

Whatever happened the Named Nurse? For those too young to remember it, this was a late twentieth-century government initiative based on the ‘Primary Nursing’ ideas pioneered by (amongst others) Professor Alan Pearson at Burford Hospital. In a nutshell, the nursing care of every patient was supposed to directed by a ‘Primary Nurse’ and at least one ‘Associate Nurse’. These nurses would liase with the patient and family and collaborate (‘collaboration’ was very much a buzz word) with them to produce of a set of long- and short-term goals for the patient to achieve over the course of the admission. These goals would be regularly re-evaluated and updated, again in consultation with patient, family, and other relevant professionals. The Primary Nurse would also be the lead figure in co-ordinating the patient’s discharge.

In Primary Nursing’s most developed form, as envisaged by Pearson, it was the dynamic relationship between nurse and patient that was at the heart of nursing care and that was proposed as a form of therapy in itself. In Named Nursing, this further refinement was – arguably – absent, but it was still envisaged that a single nurse would be responsible for the co-ordination of each patient’s care for the duration of their stay on any single ward. For Named Nursing be a reality, all the Named Nurse’s patients would need to be grouped together in the same area of the ward and the Named Nurse would work exclusively in that area every shift.

Named Nursing had its problems – so much so that almost no trace of it survives in the way most wards organise their workload today. Firstly, it’s difficult to deliver: it requires a high level of commitment from practitioners, and this is something that not everyone is always able to give. Allen (2001) found that even amongst those who were meant to be practising it, it was viewed as just another paper exercise, frequently granted only a grudging ‘ceremonial compliance’. Secondly, Named Nursing works best in specialisms such as rehabilitation, where patients stick around. By contrast, the modern-day emphasis on rapid throughput and early discharge mean that patients are here today and gone tomorrow and there is no time to develop any kind of relationship with them, let alone a ‘therapeutic’ one. Thirdly, changes in working practices have seen many nurses switch to three twelve-hour shifts a week instead of the traditional five seven-and-a-half hour shifts. Continuity of care has inevitably suffered, but many nurses feel they now enjoy a better work-life balance, which has to be a good thing. Faced with all these difficulties, Named Nursing was not so much discredited as quietly abandoned. But is it about to make a comeback?

On this issue, the Francis Report is distinctly muddled. At one point, Francis says that ‘Hospitals should review, with a view to reinstatement, the practice of identifying a…nurse who is in charge of each patient’s care, so that patients and families are clear who is in overall charge of that care’ (Executive Summary, Pt 1, para 211, my italics). This could be read as a straightforward plea for Named Nursing. But in his recommendations, it translates into ‘Each patient should be allocated for each shift a named key nurse responsible for coordinating the provision of the care needs for each allocated patient. The named key nurse on duty should, whenever possible, be present at every interaction between a doctor and an allocated patient (Recommendation 199, my italics). Could it be that M’Learned Friend hasn’t done his nursing homework? Does he understand that he is conflating two different systems of care delivery (and that the second one more-or-less describes the current situation anyway)?

The next question is: do we want Named Nursing to come back? To the public, the idea of a single nurse with whom they can develop a relationship of trust and understanding may seem like a welcome injection of common sense. But ironically, it is the behaviour of some sections of the public that may make Named Nursing unworkable: liberal partaking of state-sanctioned invitations to criticise and question have led nurses to feel that far from forming closer relationships with patients, the best strategy is to back off and stay out of the firing line. Interestingly, even feminist writers reject Named Nursing. They argue that its agenda is more about advancing nursing’s ‘professionalising project’ than about providing high-quality patient care (1) – after all, the template for the Named Nurse is plainly the consultant doctor.

And yet. Contrast Named Nursing with Intentional Rounding – nursing’s current fad – and what becomes immediately obvious is the sheer intellectual poverty that currently besets us. Where Intentional Rounding is reductionist, self-limiting and driven by cynical management imperatives, Named Nursing is rich and flexible and has, above all, the potential to give us something nothing else has, before or since: a conceptual foundation on which to build an integrated theory of nursing. Difficult? Yes. But part of the skill of nursing should be to break down prejudices, change minds and show what effective health care can be. The return of the Named Nurse, if it can be made to work, might just prove a far more effective springboard for that than any amount of Intentional Rounding.

(1) See for example Salvage, J (1992): ‘The new nursing: empowering patients or empowering nurses?’ in J. Robinson, A. Gray and R. Elkan (eds) Policy Issues in Nursing; Buckingham; Open University Press.

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

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