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Are you having a laugh?: The Politicisation of Compassion in NHS Nursing

October 15, 2013

Pillows, as anyone who has spent even the briefest time in hospital will tell you, are the ultimate in-patient status symbol. They function as campaign medals. As a general rule, the number of pillows a patient has accumulated to cushion himself against the harsh realities of ward life is a pretty reliable indicator either of how long he has been there, or of how successful he is at persuading the nurses of his discomfort. I looked after this Greek bloke once. Thanks to what I might describe as his easy charm, he had secured for himself no less than seven – yes, seven! – pillows, all piled up in a gravity-defying stack after we made his bed. One of the other patients eyed them enviously.

“Bel” he said finally “why has X got seven pillows?”

I unconsciously moved centre-bay. “Shall I tell you why X has got seven pillows?” I said.

The patient, catching my music hall stage act drift, replied in the same spirit. “Yes!” he said. “Tell us why X has got seven pillows!”

“I’ll tell you why X has got seven pillows!” I said. “X has got seven pillows because…” (pause for dramatic effect) “they’re his big…fat…Greek…BEDDING!” Oh my God! Laugh? We nearly broke the bed pan washer. For ages afterwards, I was number one nurse in that bay.

I love connecting with patients through humour. Humour – as free as the air and available for everyone to partake of, or not, as they see fit – is the last refuge of the nurse refusnik. It’s what compassion used to be before the Prime Minister and the Chief Nursing Officer for England decided to re-brand it and pitch it back to us as some kind of Big Ticket Corporate Strategy. If you want to understand the difference between the respective positions of humour and compassion in nursing, ask yourself this: what would a joke sound like if it was written by a committee?

In my two previous posts, I looked at recent thinking about compassion, and at current political trends in health care organisation. In this third post, I want to bring the two strands together and pose a difficult but important question: has compassion become politicised, and if so – what will be the long-term effects?
6th February 2013 was a very black day in the annals of the NHS. The Francis Report was published and its verdict on nursing was damning.

Some commentators have suggested that the number of avoidable patient deaths at Stafford Hospital has been exaggerated; others think the pervasiveness of unacceptable standards at the hospital has been similarly overstated. I am not in a position to make a judgement on this. Neither do I believe that politicians rejoiced in the suffering of others; I’m sure they were every bit as horrified as the rest of us by the evidence presented to the Enquiry. But at a time when the government was trying to make the case for opening up the health service to competition, anything which encouraged the public to question the ability of the NHS to provide decent care can’t have been entirely, shall we say…unwelcome. And the instrument through which this questioning has been accomplished is – compassion.

In their reaction to the Francis Report, ministers made repeated references a perceived lack of compassion amongst nurses: David Cameron floated the idea of linking nurses’ pay progression to the ability to demonstrate compassion and we also had the much-publicised initiative to make prospective nursing students work as Health Care Assistants before commencing their training. And yet the truth is that there has never been any real evidence that modern nurses as a whole lack compassion. Looked at in this way, the government’s obsession with the c-word seems more like a self-serving attempt to stir up public anxiety firstly by focussing on a soft target (nurses are notoriously unpolitical) and secondly (and totally outrageously) by tapping into lubricious societal stereotypes about good girls gone bad in the moral and – by extension – sexual  sense, and in need of a strong man to bring them back into line. The fact that the compassion debate served as a convenient distraction from the other big story – massive, politically-driven NHS re-organisation – was just an added bonus.

But in truth, moves towards ‘packaging’ compassion – ready for the transition to a market economy in health care – were already quietly under way well before the publication of the Francis Report. Government-sanctioned ideas like Intentional Rounding and (less overtly) the 6Cs are arguably intended to act as markers for organisations putting together a business case for running health care provision. In deciding who will be the recipients of health care contracts, Clinical Commissioning Groups will be looking for the existence of compassion-denoting/promoting indicators within each bid. Whether the adoption of Intentional Rounding is really a reliable guide to the presence or absence of compassion is, as anyone who has ever worked with it will know, open to question; but we’re in the realms of marketing men here, not nurses.

The future of compassion in NHS nursing is uncertain. While the media hullabaloo of the past few months may have been politically expedient at the time, the upshot is that real improvements in compassion in the NHS are now expected. But because no one really knows how the public identifies or conceptualises compassion in the public services, this would be a big enough ask at any time; against a background of financial constraints putting NHS staff under ever greater pressure, it looks like a decidedly risky strategy. Not – it should be stressed – because nurses lack compassion, but because demonstrating compassion often takes time. Conversely, the existence of ‘compassion-denoting/promoting indicators’ should not, on its own, be taken as a guarantee of compassionate care.

The alternative, as suggested by Dr Anna Smajdor, is to get compassion out of nursing altogether and focus instead on outcomes, via the medium of ‘measurable outcome improving behaviours’. This idea has a lot to recommend it and is in line with the shift from so-called ‘process’ to ‘outcome’ measures which is currently the focus of much activity in other parts of the health service. However, since the government has invested so much political capital in compassion specifically, dumping it now would involve not only massive climbdown and loss of face – it also risks leaving the many young nurses who have enthusiastically embraced the gospel of compassion with a profound feeling of betrayal.

Personally speaking, I’m just glad that ‘humour’ doesn’t begin with a ‘c’; at least one thing’s got a built-in safeguard against anyone getting their mucky mitts round it…Excuse me? What d’you say again? It’s been re-branded as ‘comedy’? With patented ‘laugh-o-meter’ consoles on every bed? Oh for Pete’s sake! I can’t take any more of this! Somebody get me out of here…PLEASE!

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