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Goodbye to all that: How the Health and Social Care Act could change the nature of nursing

January 14, 2014

Late last year, something interesting appeared on a blog called Primett’s Perspective. It’s not a nursing blog; in his bio, the owner says he is a ‘Family Man, Businessman…Labour Party Member, Campaigner and Candidate for 2015 Local Elections’. The post that caught my eye wasn’t written by him. His role in all this is limited to introducing it as ‘a diary-piece I saw, that I simply had to share’. The post itself is an account of a day in the life of a newly-qualified nurse on a surgical ward at an unidentified hospital – and it’s a catalogue of unmitigated horror.

Staffing shortages mean the writer is left as the only trained nurse for twelve acutely ill and heavily dependent patients. Lurching from one crisis to the next, her brave but ultimately losing battle against a engulfing tide of death, dementia and bodily fluids is hindered, rather than helped, by the interventions of bad-tempered doctors, aggressive relatives and unsympathetic managers. You can almost hear the despair in her voice as she pleads for time for ‘basic’ nursing, ‘to wash my patients and brush hair and help put hand cream on’.

In some ways, the post is a con: the author admits (in a comment) that the events it chronicles are ten years old, but asserts that ‘little has changed…it is just the same out there on the wards as it was’. The almost unanimously supportive tone of other comments indicated that most readers agreed with her. Alone amongst contributors, just one person, a ‘senior nurse’ called Ben (and no, I have no idea who he is) was prepared to stick his head above the parapet and suggest that it was ‘worrying that after years at uni all [the writer] wants to do is…chat and wash patients. This is an important part of the job indeed but not all of it’. What followed was a revelation. And I don’t mean in a good way.

Firstly, the depth of resentment that some nurses harbour towards their managers was truly staggering. Reaction to Ben’s interventions reminded me of nothing so much as an episode from school when a pack of baying teenage girls surrounded some unfortunate bloke whom they suspected (wrongly as it turned out) of two-timing their friend: “OMG, I cannot believe you are a nurse”; “You have no idea and no compassion”; “your responses are born out of naïvety, ignorance or stupidity”; “you are judgemental, patronising, extremely lacking in empathy, very short-sighted and…everything that’s wrong with the modern NHS”. Plainly, managers are far from blameless – emotions this strong are not engendered without reason – but one could hardly wish for a more graphic illustration of the divisions that hold nursing back.

What concerned me even more however, was that although Ben could have been more sensitive in places (his repeated references to the then-twenty-one-year-old author as ‘this girl’ were particularly jarring) he also calmly and courteously asked a number of very important questions about the future direction of nursing and the place of ‘basic’ care within it. Not one person chose to debate these issues with him. Instead, he was subjected to a barrage of unmerited personal attacks and some highly emotional ranting about the role of trained nurses in washing patients. If I said the profession was shamed by this display of nurses’ intellectual acumen – not to mention their tolerance of others’ views – well, I wouldn’t even be coming close.

Because like it or not, Ben, in his blundering way, put his finger on an extremely prescient point. “Modern nursing” he said “is becoming more advanced and technical with a greater level of responsibility…the fact is we are being challenged to be compassionate and scientific at the same time…it does not take years at university to chat and wash people”. For two reasons, this question – how much ‘basic’ care qualified nurses should be doing – is urgently relevant: firstly because of the push for ‘safe staffing’ and secondly because of the implementation of the Health and Social Care Act.

Let’s look at safe staffing first. Many nurses welcome the new focus on staff numbers as a positive development, and of course they’re right. But what is meant by ‘safe staffing’? Demands for a national inpatient minimum ratio of eight patients to one trained nurse are based largely on the work of Professor Peter Griffiths and his team at Southampton University, which found that increased ‘failure to rescue’ was associated with higher numbers of patients per trained nurse. The key phrase here is ‘failure to rescue’ – that is, failing to prevent or reverse deterioration in a patient’s condition. The goal of safe staffing, in other words, has got nothing to do with brushing hair and creaming hands – and everything to do with increased monitoring and the rapid instigation of technical interventions aimed at avoiding complications and saving life.

Turning to the Health and Social Care Act, while it’s true that Clinical Commissioning Groups will be looking for satisfactory staffing levels when deciding where to purchase care, they will also be expecting to get value for money from nurses who work in those areas that have won the right to provide services. The idea that expensively-educated and highly-qualified nurses could spend their time carrying out care that less well-qualified and less well-paid staff could do just as well is simply not a sustainable business model. And business models are what the Health and Social Care Act is all about.

The reality is that – even without the creeping ‘technicalisation’ of nursing which has already been happening for decades anyway – almost all recent developments both within nursing and outside it are likely to gradually remove trained nurses from ‘basic’ care. The only brake on this process was applied by the government itself when it threw out Robert Francis’ recommendation on the regulation of Health Care Assistants (HCAs). The regulation of HCAs would have accelerated the transfer of direct patient care away from Registered Nurses because, as I have argued before, it would have encouraged HCAs to draw an exclusionary boundary around their own area of specialist knowledge – direct patient care.

Against this backdrop, what then is the future of nursing? For some branches, it seems inevitable that it will look increasingly like a successful scheme initiated in Kettering Hospital’s ED Majors, where a small number of Advanced Clinical Practitioners work at a level equivalent to a Foundation Year 2 junior doctor. Their role encompasses making direct referrals, prescribing medications and ordering diagnostic tests. Whether an initiative like this devalues medicine is something I’ll leave it to my medical colleagues to debate. But if you’re asking me whether it’s’ really’ nursing, then yes, I don’t see why it isn’t. If it’s expediting optimum patient care, what’s the problem? Our role is to change with the times while continuing to do our best for patients; our role is emphatically NOT to waste time pining over the loss of a world that’s gone. Compassion is not the issue here: compassion is a given. The challenge is adapting compassion to a new environment.

Registered Nurses who maintain that only ‘basic’ care is ‘real’ nursing have two options: either wake up, and fight your corner a lot more convincingly than you managed to do on the Primett’s Perspective blog; or adjust your conception of what is meant by ‘real’. Because as Ben points out ‘being both technical and compassionate is possible’. While you’re figuring it out though, I’d just like to add that if ever I’m in hospital and I’ve got the choice between Ben and anybody else from that blog post as my named nurse, I’ll take Ben every time. At least he can think for himself.

For the Primett’s Perspective blog, see: http://primettsperspective.blogspot.co.uk/2013/08/nhs-in-crisis-very-sad-piece-from-newly.html#comment-form
For a description of the scheme at Kettering Hospital, see: http://rcnpublishing.com/doi/full/10.7748/ns2013.12.28.16.48.e8294

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