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Divide and Rule: Nursing’s Generation Game

October 29, 2013

Care and compassion (to paraphrase Philip Larkin very badly) began in two thousand and twelve (which was rather late for myself). Or at least, that’ s the impression you’d get if you’ve been following the latest updates from the Care Makers’ Hub. According to this website, Care Makers are ‘student and newly qualified nurses, midwives and healthcare assistants who act as ambassadors for the 6Cs…They…creat[e] a unique link between this national policy and strategy to the frontline’*. Additionally, they have ‘a passion for ensuring patient-centred, compassionate care and spreading the word about the 6Cs’. One thousand of these volunteers are set to have been recruited by the end of the year.
Now you may say (and some of you probably will) that I’m nothing but a jealous, frustrated, irrelevant old has-been – but as an older health care professional, I feel pretty hacked-off about Care Makers. In fact, I’m totally flamin’ furious about them. You wanna know why? I’ll tell you why. In opening up Care Makers only to students and newly-qualified nurses, the Chief Nursing Officer for England (at whose behest Care Makers were created) is signalling to those of us who are in the, let’s say, more mature age bracket that we have absolutely nothing to contribute and what’s more that we’re so uncaring, so washed-up and so ‘whatevs’ about the jobs we’ve sold our very souls to – that re-programming by a bunch of pumped-up Johnnie-come-latelies is our only hope. That’s very, very insulting isn’t it? If you’ve got no degree, you’ve got no brains? Is that it? If we’re such an enormous burden, why not just pension us off altogether and let the youngsters run everything? What’s that? Too expensive? OK then – new strategy: just make us feel really, really unwanted, and pray we’ll get the message and clear off out of it of our own accord.
Actually, this isn’t really how I feel; though I think I’d be perfectly justified if it were. But there are signs that (minus added rant, which I slung in there just to get you all shouting at your screens) others are feeling something similar. After last week’s Care Makers Conference in Leeds, one nurse tweeted to the WeNurses Twitter feed that ‘us old gals have a lot to offer and feel a little left out of…care makers’. Another said ‘[it] made me think..should there be something to mobilise the guys at the other end of spectrum with 25+ years service?’ The idea was floated of pairing up Care Makers with older ‘Care Buddies’ ‘so that experience can be drawn on and newbie keenness can be spread’.
It’s a great idea. If it ever becomes reality, I’d be half-tempted to sign up for it myself. But that’s the problem – as the Care Makers Hub itself proclaims ‘[Care Makers] creat[e] a unique link between…national policy and strategy to the front line’. In other words, if you’re a Care Maker, your  role is to act as an organ for and enforcer of government policy. After years and years of top-down re-organisation and re-re-organisation, it was obviously feared that the more experienced amongst us would by now be far too battle-weary to fancy nailing our colours to the mast of what we couldn’t be trusted not to see for exactly what it is: another gimmick. Comments made about the scheme on the Nursing Times website confirm that many nurses do view it as exactly this. So the bottom line is: older nurses have been deliberately passed over in favour of a more malleable younger cohort. Our hard-won experience is the very thing that excludes us.
Strangely though, the implicit ageism of Care Makers isn’t what upsets me the most. No, what really sickens me about the whole Care Makers project is the way it cynically subverts the energy and idealism of novice nurses – firstly by encouraging them to believe that their older colleagues represent some kind of a problem and secondly (and even more unforgivably) by using Care Makers as instruments in the covert furtherance of political agenda. I want to be clear, though, that this isn’t personal: as individuals, I admire all you Care Makers out there and I’m heartened by your enthusiasm and genuine desire to make nursing better; I just think you’ve been sold a pup.
Take ‘boat-rocking’, a Care Maker buzzword. The 6Cs, which Care Makers are supposed to champion around their respective places of employment, are inextricably linked to the Health and Social Care Act. The big point of the 6Cs is, in part, to provide a handy conceptual framework for the nursing component of organisations getting ready to competitively tender for NHS contracts. If you’re a Care Maker and you support the Coalition’s vision for the NHS, you’ve got no problem; but if you’re a Care Maker and you don’t support the Coalition’s vision for the NHS, you may need to ask yourself what the hell you’ve gotten into. Either way, it’s hardly ‘boat-rocking’. This blog is ‘boat-rocking’. Acting as a mouthpiece for government policy, whichever way you play it, is really not.
The irony of all this is that in our new era of social media, nurses have more opportunities than ever before to connect with each other, exchange ideas, come up with solutions from the grassroots and develop an identity that transcends the narrow student/newly qualified/old lag labels. Forcing upon us arbitrary divisions such as ‘Eligible to be Care Maker/Ineligible to be Care Maker’ on the basis of nothing more than a presumed susceptibility to the blandishments of government doctrine is  not going to mend situations like the one so eloquently articulated in a recent poem on the WeNurses Community Blog. What the student writer is describing is not new: there have always been pockets of negativity from trained staff towards students – but it’s exactly the type of problem that we urgently need to solve if we are ever going to move forward. Care Makers, however, with its queasy aftertaste of divide-and-rule, is not the answer. Brothers and sisters, resist this plan to set nurse against nurse!
What are required are initiatives that bring all grades and specialities of nurses together. Nurses who trained years ago need time to update and familiarise themselves with what students are taught today. so that placements can better reflect classroom learning and mentors do not feel threatened into defensiveness by ‘more academic’ undergraduate nurses. All of us need to embrace social media: student blogs make great light reading, and are an excellent way for the geriatrics amongst us to remind ourselves of what it feels like to be a new nurse. There also needs to be a much more determined effort to bring Evidence Based Practice onto the wards so that we can all unite around it.
As a profession, what we really need to do is grow up – but we can’t do that while the government continues to compel us to act like a family of needy children competing for parental attention. And – if I may return to Philip Larkin by way of conclusion, we all know what his other famous opening line had to say about the long-term effects (on the offspring) of the parent-offspring relationship ( for anyone who doesn’t).

* Correct at time of writing. (Possibly) as a result of publicity generated by this article, the text now reads: ‘Care Makers are nurses, midwives, allied health care professionals and heath care assistants who act as ambassadors for the 6Cs’.

For Philip Larkin’s poem Annus Mirabilis, see
For the Care Makers’ Hub, (which if I may say so is a remarkably unimpressive web site with links that don’t work and references to sections that don’t exist), see
For a Nursing Times article on Care Makers from last January, complete with very some disgruntled comments, see
For the WeNurses poem, see
For a fascinating article about how boat-rocking economics students at Manchester University are challenging their taught syllabus, see

Right of Reply: subject to editorial standards being met, Grumbling Appendix would be willing to run a response to this article if any Care Maker would like to send me one. Contact via Twitter.

  1. You go, girl! Interesting viewpoint.

  2. CareMakers…. Makes you want to wage a form of nurse jihad against the government!

    Adding to the controversy, on the wider point, Paul Gilbert makes some interesting observations about how in our modern society an ever increasing culture of competition and striving to get ahead switches off the compassionate mind, and in turn loosens the brakes on bad events happening. Could all this emphasis on ‘science’, ‘evidence’, ‘models’ and the development of a ‘critical mind’… the essence of nursing as frequently portrayed on Twitter (the patient really ought to get more of a mention lads), be at the expense of the expression of fundamental, intrinsic human values?

    In my experience, it often feels as though nurses are becoming harder people in response to the often unreasonable demands being placed on them by working in the NHS. Perhaps the true reality however is that it was always thus, thinking back to my own experiences as a patient over 40 years. In a poorly resourced working environment focused on targets and tasks, compassion (giving thought, time, energy and space to others, including your fellow team members) can sometimes be seen as a weakness or even be disadvantageous to career progression. One might even be tempted to ask whether the compassionate mind is one which is more likely to be bullied in this context, forcing it to keep its compassionate head down as a matter of survival… a kind of bunker mentality?

    Expanding on Gilbert’s thesis, it’s arguable that the nursing profession in its recent rush to embrace all-degree status is in a very small way contributing to this competitive groupthink by inevitably pitching nurses against each other (and other professions such as medicine and allied professions) in a race for recognition, career progression and status. Unhappily, in the process some nurses may have taken their eyes off the ball, i.e the patient.

    For many nursing jobs today even a first degree is not enough and masters study is becoming a requisite for most specialist nurse jobs. In some hospitals I’ve worked at career progression is turning into a contest of academic qualifications over experience. Where will this stop? When we finally become doctors? Hmmm. And what effect is all this extra, unpaid study/part-time working having on home lives and the continuity of patient care? Are nurses becoming their own worst enemies by undertaking all this extra-curricular work, even if it is done with the best interests of nursing and patients at heart? An what about those who refuse to join up to this academic gold-rush. Are they to be thereafter treated as second class nurses?

    On one level, I’m really pleased that people want to ‘better’ themselves, but I am also concerned that when you take into account the practical realities and stresses of day-to-day nursing, the benefits of degree entry nursing are overstated. One important and often overlooked consequence is that many good people are being excluded from entering nursing. I’m thinking mainly about the countless superb HCA s, physio and OT assistants, phlebotomists, admin’ staff and others I’ve worked with, some of whom wanted to be nurses but who were scared off by the academic rigours and requirements…. some of whom just wanted to care. A balanced profession is one that embraces a range of people with diverse talents, not just academic ability.

    I’m sure I’ll get a lot of stick for this.

    Like many, I’ve always felt my training began on ‘qualification’. I might venture to say that a nurse who makes it through this initial qualification period, gains experience in a few different areas and then subsequently studies for a degree, brings more to the table than a newly ‘qualified’ nurse with a degree. Especially if they focus their experience and passion on an area specific to their practice and in doing so add to the evidence base by research. I’ve seen this bring about real positive change on the ground, if at times a bit too much new paperwork for the rest of us to fill in! I am not at all saying that having a degree necessarily negatively influences care. That’s totally wrong and Ann Clwyd and others should be forcefully challenged (by people like Jane Cummings) for putting that out there. Today’s entrants are more likely to challenge bad practice and bad governance. They are more likely to be enthusiastic and assertive about nursing as a discipline, although the system may soon knock that out of them. However, in the short-term, in the period after ‘qualification’, it’s questionable whether a having a degree adds the value that is frequently claimed. A degree in aeronautics is a lovely achievement, but it won’t qualify you to fly the plane. Of course you could always redesign things so the student actually learns to fly the plane during their 2-3 years training, rather than enduring endless hours of theoretical models and theory, whilst dreaming of runways. If they then subsequently want to become nurse astronauts after a few years, then great for them and great for us! However, I do sometimes get the feeling that some really good nurses are leaving front-line care completely before their time for the sunny uplands of specialist nursing and academia, when they are really needed as leaders on the ground (you know, those special people who muck in and lead by example. I love those people).

    As to the current debate. I am very sorry for Ann Clywd’s sad loss, but private grief does not make good policy or law. I have to say in my career, I have seen many of the things she touches on in her report. Let’s get real. These are almost always isolated snapshots of poor care and in no way can be said to represent the whole of the profession. It is disingenuous to claim so. As a matter of fact, I would love Ann Clywd (if I was still a nurse), to take a walk with me to meet my former colleagues in ICU and A&E, first taking a moment to duck the broken TV flying over our heads as we walk along the A&E corridor. These lovely people have the expertise of doctors, the patience and tolerance of saints, the productivity of German factory workers and rarely complain at the end of a 13 hour shift when it’s all kicking off and they are still there, unpaid, an hour and a half later, pushing against a vaguely blood splattered glass ceiling which means that many of them will take years to get beyond even the average wage. Or my former colleagues in oncology who are still caring for patients 3 hours after clinic ended because a patient needs an urgent bed, there isn’t one, management have gone home and the nurses feel it is safer and less scary for the patient to stay with them rather than go to A&E and get lost in the system. Or my colleagues on the care of the elderly ward who are quietly and considerately washing Mr X and changing his pants and pyjamas for the 5th time today, all the time being complained at by relatives and worrying that they are letting down the other 29 patients just around the corner by taking the time to actively listen to and respond to family concerns. I could go on and on and on. Add your own illustrations here.

    To me, the CareMakers initiative is a classic Bairite diversion from the real issue and I am sad that people like Jane Cummings are spending too much time on this when they should really be agitating for change where it really matters. As an initiative it may be a useful vehicle in a social media type way for students, newly qualified nurses and anyone interested to come together and help generate a bit of pride within nursing. Well at least until these evangelistic poppets of compassion run into a brick wall of cynicism when they finally get into a position to challenge the system. As with many of these initiatives, they launch in a flourish of publicity and never get beyond the first few pages. In reality CareMakers will do little to address the lack of compassion issue… that is, if there really is a problem with compassion at all?

    On a more personal note, earlier this year I was set to move to New Zealand to work and live as a nurse. This had been an ambition for a while and I registered three years ago in preparation for the move. At the very last moment when I had a job lined up, NZ immigration changed their residency rules to require that all nurses have degree qualifications. This followed a similar change by the nursing council of NZ last year. Despite my diploma, 10 years experience in a variety of acute areas and another very good degree outside nursing, moving is now pointless as I will not gain residency under current rules. As I don’t have the money or time to study for a NZ degree, I am excluded, much like the good people I mentioned earlier above… all because I don’t have a nursing degree.


    Two-tier nursing, if it’s not already here, is coming our way real soon. This will exclude many and give the powers that be a sure excuse to downgrade diploma nurses, pay them less and force people into costly, stressful and questionable extra study with little benefit to patient care. How is this going to help nurse compassion levels?

    Steve Bradley LLB(Hons) PGDip CBIS DIp H.E Nursing

  3. Hello Steve! Er…where to start?
    On Care Makers, I think I’ve said all I want to say, both here and on Twitter, and I’m not going to start repeating myself. Especially for people who are starting out, I would not discourage anyone from participating in a scheme that could improve career prospects and provide an opportunity to network – but I would also advise a questioning attitude and a willingness to think hard about the issues raised – the possibliity that it’s a ‘classic diversion from the real issue’ being one of them!
    Two-tier nursing? Yes, agree with you there. People who have diplomas are going to end up upgrading to degrees, just like SENs ended up having to convert to RN – and no doubt they will be expected to do it in their own time and at their own expense. Sorry to hear that your experiences of trying to get into New Zealand have just served to provide an illustration-in-advance of this.
    On Ann Clwyd, the awful circumstances of her husband’s death, and the subsequent review of the NHS complaints procedure, I don’t want to say too much just now because it’s an area I want to explore in my next blog post. I would say though, that while those of us who give – and witness others giving – nursing care every day of our working lives may view instances of poor care as isolated and unrepresentative, to those for whom this is their ONLY experience of care, it’s not isolated, not unrepresentative. As care workers, we have a duty to understand the differences between the patient’s perspective and our own.
    Think we’re still on the same page!

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