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Making Sure That They Are Focused On The Caring: What the Too Posh To Wash row says about populist attitudes to women

April 28, 2013

‘It will have to be considered whether women can scorn delights, and live laborious days of intellectual exercise and production without injury to their functions as conceivers, mothers and nurses’. The Daily Mail, circa 2013? Well no, actually, the slightly archaic language rather gives the game away, doesn’t it? This is the pioneering psychiatrist Sir Henry Maudsley, way back in 1874, warning of the dangers of allowing women to train as doctors.

A comparison with an actual quotation from the Daily Mail on the day the government published its response to the Francis Report is instructive, however: ‘Student nurses are to be forced to work for a year as healthcare assistants’ it informed it readers ‘to improve compassion in the NHS. The back-to-basics approach comes amid claims that many trainee nurses, educated to degree-level, consider themselves ‘too posh to wash’’. Well, at least one lesson has been learned. Apparently, it’s no longer socially acceptable to overtly frighten women into believing that too much book-learning will turn them into unfit mothers. These days, you you have to cut to the chase. The real peril is (understood but unacknowledged by the good Sir Henry) is social mobility: if you let ‘ordinary’ girls get degrees, they’ll have ideas above their station. And then who’ll wipe the arses?

The first application to nursing of the phrase ‘too posh to wash’ is lost in the mists of time. An early documented usage was at the Royal College of Nursing annual congress in May 2004. During a speech in which he castigated ‘a small but significant minority of the new generation of nurses who say they do not want to do basic, holistic care’, a delegate from Exeter confided to conference that “If I become too posh to wash, I shouldn’t be in the profession”. ‘New generation of nurses’ was presumably a coded reference to ‘nurses with degrees’. Then as now, ambivalence about the advisability of educating nurses to degree level was evident within the profession as well as outside it.

Fast forward nine years. The RCN is again holding its annual congress. Right at the top of the agenda is an argument which, at its most basic, boils down to this same question: has the transfer of nurse training to universities produced practitioners who consider that engagement in direct patient care is an insult to their educational attainments? The difference is that now, in the wake of the Francis Report and the government’s response to it, Patients First and Foremost, the debate has become politicized. That’s right: in twenty-first century Britain, we are publicly agonising about how much education is appropriate for a occupational group overwhelmingly dominated by women.

The background to the current spat is, inevitably, the scandal at Stafford Hospital. In his Report, Robert Francis QC recommended that to counteract a perceived lack of compassion amongst nurses ‘There should be a national entry-level requirement that student nurses spend a minimum period of time, at least three months, working on the direct care of patients under the supervision of a registered nurse. Such experience should include direct care of patients, ideally including the elderly, and involve hands-on physical care. Satisfactory completion of this direct care experience should be a pre-condition to continuation in nurse training’ (Recommendation 187). In Patients First and Foremost (the government’s response to Francis) this translated into ‘every student who seeks NHS funding for nursing degrees should first serve up to a year as a healthcare assistant, to promote frontline caring experience and values, as well as academic strength’ (Patients First and Foremost, para 5.14). The battle lines between the government and the RCN were drawn.

First into the field was RCN president Andrea Spyropoulos. As Congress opened on 21st April, she slammed the government’s plans as ‘stupid’ and ‘a waste of taxpayers’ money’. The next morning, the organisation’s Chief Executive, Peter Carter was invited onto the Today programme on BBC Radio 4. Interviewed by Sarah Montague, he branded the new scheme ‘ill-thought-through’ and commented that “It simply doesn’t stack up and [poor training] isn’t the reason why there were those major failings at Mid-Staffordshire hospital”. The government was unrepentant. Later the same day, David Cameron told an audience in Derby that ‘nurses should spend some time when they are training as healthcare assistants in the hospital really making sure that they are focused on the caring’.

Lurking behind these disagreements are wider questions. Why has the public has never been convinced that nurses need to be educated to degree level? Why does that odious shorthand ‘too post to wash’ still enjoy common currency in the popular press? And even worse, why does much of the public debate on the subject appear to be premised on the belief that academic formation for nurses is not just unnecessary but positively harmful?

The late Claire Rayner, National Treasure though she undoubtedly was, often perpetuated this type of thinking. Here’s an example from 2004. Writing in The Guardian in her capacity as president of the Patients’ Association, she said ‘I have lain in bed waiting for my dressing to be done and seen a nurse who has a BSc arrive with sterile packs of instruments and dressings carried in her bare hands, rather than on a spotless trolley. And then she put the packs down to be opened on my far-from-aseptic bed’. The reason this happened was very clear: ‘Nurses are now trained in universities, with occasional forays to hospitals where they only observe, never work’.

This idea, that moving nurse training into universities somehow removed trainees from patients seems to be widely believed. On the 21st April edition of the Today programme, the MP Ann Clwyd was brought in to debate the subject with Peter Carter. She said that her recent campaign against low standards in NHS care had elicited over two thousand sympathetic letters and e-mails “all saying the same thing: nurse training is not fit for purpose, no hands-on-experience…need to return to apprenticeship”. In vain have student nurses and their tutors pointed out that fifty per cent of a three year training course is spent on placement. No one wants to hear it. And the reason no one wants to hear it? Because it conflicts with the populist agenda around female education that is now revealed as the dominating force in the whole debate.

The subtext of ‘too posh to wash’ is a modern manifestation of the ancient anxiety that education for women will somehow result in the overthrow of social order. Because of the undeniable problems it currently faces, nursing has, for now, become the focus of these fears. As a slogan, ‘too posh to wash’ neatly encapsulates the reactionary message that (for reasons requiring further scientific investigation), education does not have the same effect on aspirant nurses as it is usually thought to have on the rest of the population. It does not, for example, make them more constructively critical; it does not make them more articulate in the cause of their patients; it does not make them more innovative; it does not leave them better equipped to manage, teach and inspire. No. It makes them more snobbish. And what nice young man wants to marry a snobbish woman?

The solution, according to this logic, is to take nurses down a peg or two. Make them reconnect with that beautiful feminine instinct which – uncontaminated by silly intellectual pretensions – is the best guide to good  care. Leave all the hard stuff to men. They understand it better anyway. What is really depressing is that by its decision to not just accept Francis Recommendation 187, but indeed to strengthen it, the government is signalling its acquiescence in this outrageous sexist/classist claptrap. What they have come up with is, in effect, a sop to the very worst kind of populism – the most damaging effects of which are felt by nurses themselves.

The apparent vindication of the notion that nurses have lost their compassion seeps into public attitudes to nurses, not just in the abstract but in the flesh. In a perceptive series of articles for The Independent last year, Christina Patterson spoke to a nurse who was planning to leave her job because she was burned out and feared she no longer had compassion. She said: “a very difficult, litigious and often aggressive public, and very frightening and stressful situations, and knowing our great accountability, makes us very stressed at work”.

This rings true. Primed by the media, patients and relatives routinely arrive at hospital expecting to find uncaring nurses and metaphorically armed for combat. Nurses meanwhile, wearied by constant confrontation, react by retreating from face-to-face contact and into paperwork – of which there’s no shortage. Robert Francis QC blamed the failings at Stafford Hospital on ‘the culture’. Perhaps he should have paid closer attention to the culture beyond the gates. The one which denigrates educated women as a way of hiding its fear.


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