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Bedpans and Bandages Episode 6: Mind your language

March 25, 2014

So, at the end of a week when I was summarily banished to the Twitter naughty step for being so catastrophically off-message as to utter the dread phrase ‘basic care’ in a public place (it was the character limitations wot drove me to it, Your Honour, and I did put it in inverted commas), it was interesting, to say the least, to note that the ‘B word’ cropped up no less than three times in last week’s episode of Bedpans and Bandages. First we had (oh yes!) ‘basic care’ (Dany cleans a patient who has been incontinent). Then we had ‘basic checks’ (Alistair introduces himself to Adam, a young man who has fractured his leg). Finally we had ‘they’re the basics’ (Joanne explains the importance of a thorough knowledge of both hand-washing technique and the NMC Code). So can it sometimes be OK after all for nursing to go ‘back to basics’?

There are plenty of reasons to answer ‘no’ to that question. From a quasi-political standpoint, you could take the view that nursing is a highly skilled profession which should mount robust resistance to any attempt to demean it with the ‘basic’ tag. Or you could adopt a more philosophical line and argue that because all nursing care, even the most mundane actions, has the potential to be life-enhancing and transformative for the persons involved, all nursing care is therefore equal. My personal hunch though, is that current phobias around the use of this particular no-no actually have less noble origins. I think they stem partly from society-wide anxieties about risk aversion and respect (‘if I say the task is basic, could that be interpreted as meaning I think the person performing or receiving it is also ‘basic”?); and partly from more nursing-specific jitters. The ‘too posh to wash’ degree nurses of media scare-stories countered by ‘no such thing as basic care’.

But denying people the language to describe a situation does not mean the situation has ceased to exist. One of the more intriguing blogs I read in the last week was written by someone who wanted to highlight a common student dilemma that has so far been airbrushed out of Bedpans and Bandages. Namely, how should you respond when your placement area is so short-staffed that you come under pressure to forego your learning opportunities and become simply an ‘extra pair of hands’?

The writer didn’t present a definitive answer. But what he did (possibly fortuitously) do was paint a fascinating portrait of the deeply-demarcated ward environment that lies at the heart of his problems. We are in a place where a Health Care Assistant (HCA) might ‘ask [a student] to wash a few patients in the morning whilst [his] mentor is writing notes or preparing paperwork for a discharge’. The student could refuse, but then ‘you would only be sitting next to your mentor when you could be on the ward helping out with ‘real work”. Admittedly, the writer put the words ‘real work’ in inverted commas – but we all knew what he means. And by conjuring up images of effete nurses sitting at desks while muscle-bound HCAs toil away behind them, ‘real work’ is arguably an even more divisive phrase than ‘basic care’.

Other euphemisms are available, of course. Is ‘fundamental’ (as in ‘Certificate of Fundamental Care’ – Camilla Cavendish’s suggested name for the proposed new national Health Care Assistant training scheme) really any better? It’s a question that’s given added urgency by the looming shadow of the Health and Social Care Act. In order to ensure that they are getting value for money, there is every chance that the Clinical Commissioning Groups in charge of local services may demand that the nursing activities they purchase be broken down into broad groupings. Numbers and pay points of staff who are competent to perform each of them will be required to complete the picture. Then you can start making comparisons.

For comparisons to have any meaning however, some kind of ‘banding’ of the various types of nursing interventions becomes inevitable. And while ‘basic’ and ‘fundamental’ would probably be ruled out as descriptors on the grounds that they’re too vague, it wouldn’t be unreasonable to expect something along the lines of ‘level 1 nursing tasks’ (can be carried out by Health Care Assistant), ‘level 2 nursing tasks’ (can be carried out by any Registered Nurse) and ‘level 3 nursing tasks’ (can be carried out only by a Clinical Specialist with additional training). A hierarchy of intervention masked by neutral language? Would we be any happier with that?

One of the best bits in Bedpans and Bandages Episode 6 was when Alistair was given a rare opportunity to take his patient to theatre and watch his surgery. What really stood out was how much both he and Adam – and Adam’s worried mum – appreciated his accompanying of Adam throughout his hospital journey. Mum summed it up best when she said “he’s been there for Adam from the beginning, sort of looking after him from Day One, to surgery, through to going home”. Contrast this with the (seemingly) rigid compartmentalisation of work described by @nursevink in his blog post and a rather different picture emerges – one where the solution rests not on proscribing certain words, but on building the strength of the nurse-patient relationship.

Bedpans and Bandages has been criticised in some quarters for not giving a true picture of student nurse life. But one area where art definitely seems to imitate life is in the (again, possibly fortuitous) characterisation of the nurse-patient relationship. What we are presented with is a disjointed, fragmented narrative – different students every week, different patients every week, little continuity.This is uncomfortably close to what patients all-too-often claim is their experience of health care too.

Named nursing, out of fashion for so long, is supposedly poised for a come-back. For me, it can’t come fast enough. If working practices encouraged individual nurses to develop proper partnerships with individual patients, and provide whatever input – washing, counselling, discharge planning – that patient happened to need at the time, perhaps care would have the chance to become a truly indivisible whole.

In the meantime, let’s chill. Stressing over political correctness (because that’s what this new hard line about ‘basic care’ really is) just makes us look insecure. We’re always going to need a vocabulary to differentiate the various aspects of nursing, just as we still need a vocabulary for the numerous other phenomena we’d like the world to believe we’ve left behind. Take the word ‘normal’. As a  adjective applicable to nursing, ‘normal’ was cast into the outer darkness years and years ago and never rehabilitated. But to to the wider public, it still has currency. Terminally-ill Syd used it in a conversation with Dany in Episode 5. “Got to get me out of here” he told her. “Yeah…looking at all this, it’s got to be. I know I shouldn’t…if I was normal, you’d just…”.

How did Dany respond? She did what 99.95% of clinicians (me included) would have done in the same situation: nervous smile, too-quick interruption, upbeat recitation of standard mantra: “but you are normal!”. Thankfully, Syd knew better. Turning away with a weariness permitted – perhaps – only to those who know they won’t have to endure the absurdities of this world for much longer, he said “Ah, you know what I mean”. We do, Syd, we do. Even if we’d like to pretend we don’t.

For @nursevink’s blog for Student Nurse Blogger Collective, see
http://britainsnurses.co.uk/news/blog/the-bulletin/stnbc-supernumerary-i-beg-to-differ

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2 Comments
  1. Marieke permalink

    Interesting read. I would like to clarify that with “real work” I meant to highlight the exact problem that we have. I personally do not see how doing correct discharge paperwork is not also part of the real work of nurses but the general public, and a good deal of HCAs, feel that washing, feeding and toileting is Real Nursing. I was trying to convey the feeling of being torn between feeling I am seen as avoiding getting my hands dirty and muck in, and doing other aspects of nursing.
    Maybe I suffer from this more than others as I have always been quite worried about how I am being perceived. I would hate the idea of an HCA telling other people that I am not willing to help. And so I help them. But it does make me feel unhappy because I know I have other things to learn.

  2. Thank you. I thought your blog raised a number of important issues, and I would have commented on-site, but for technical reasons I was unable to do so .In a nutshell, what you gave us was a very vivid and succinct picture of ward culture. Part of the problem is that nursing has historically defined itself in relation to other occupational groups. In the past this ‘other’ was of course medicine. Unfortunately, the result of habitually defining itself as ‘what someone else is not’ has resulted in nursing’s weak self-image and a difficulty in articulating exactly what special contribution nursing makes. Politicians and managers have exploited this situation to pile numerous new duties like ‘bed management’ onto nurses.
    The irony is that as the nursing and HCA roles slowly but surely diverge, the HCAs have the better side of the bargain – theirs is a role that is now easier to define and explain than that of the qualified nurse. The last thing nursing needs is another group of staff to tell them what their job is. The challenge is to define the job ourselves, and then build on that definition.

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