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Pride and Prejudice

April 22, 2014

Amidst all the tearing of hair and beating of breasts that followed the publication of his Report, one aspect of Robert Francis QC’s magnum opus went almost entirely unnoticed: it is a document profoundly revelatory of the prejudices of its author, its assumptions entirely underpinned by a mindset already convinced of the natural superiority of the (male-dominated) professional classes.This is nowhere more striking than in the differences between the recommendations relating to medical and nurse training. As a result, a snobbish and artificial distinction was laid down, which not only flies in the face of recent research but risks legitimating regressive and uninformed policy on nursing for years to come.

Let’s look at the recommendations on nursing. Here, the Report takes as its first principle, upon which all the rest is founded, the importance ‘an increased focus in nurse training, education and professional development on the practical requirements of delivering compassionate care in addition to the theory’ (recommendation 185). Note the interplay of the words ‘practical’, ‘compassionate’ and ‘theory’ in that sentence – ‘practical’ is used to amplify ‘compassionate’ while ‘theory’ is placed at a polite distance; the message is obvious. When we turn to medical training however, there is no mention of ‘practicality’ or ‘compassion’ or anything of the sort; instead the Report concentrates on the creation of a good learning environment and the potential of medical students to be drivers of improved patient experience. Well I’m sorry, but shouldn’t these things be important for both doctors and nurses?

But the real power of Robert Francis’ blinkered attitude lies in its usefulness to the political agenda. He may not have meant it to happen, but in a post-Francis world where everything is obsessively measured against the fine print of his Report, Francis has conveniently provided policy-makers with an excuse to focus not on structural problems like underfunding and increased workload, but instead on the perceived individual failings of an already-downtrodden group. Last week, with the announcement of a new Nursing and Midwifery Council/Health Education England sponsored review of nurse education, we got a ringside seat as the implications of this unfolded in front of us.

In an article that opened with the words ‘nurses must learn to be more compassionate, ministers have said’, the Telegraph quoted Health Secretary Jeremy Hunt’s opinion that ‘changes [to nurse education] were needed to tackle scandalous failings in care and ensure that treating patients with respect and dignity became the top priority of all staff’.

Brothers and sisters, these are the words attributed to Her Majesty’s Secretary of State for Health: this is what he thinks of you. It shouldn’t make you angry. It should make you incandescent. He’s insulting you; he’s publicly declaring his belief that treating patients with respect and dignity is not your top priority. And not content with that, he has also served notice on the contents of the review. And guess what? Surprise, surprise, the spotlight will be on ‘compassion’ – even though there is no hard evidence that nurses as a group lack compassion and plenty of evidence that better educated nurses produce better patient outcomes. And there’s more! Even before the terms of reference have been published, Hunt the Omniscient has peered into his crystal ball and proudly declared that he knows what the outcome will be: ‘changes are needed!’ For Heavens’ sake! How much more of this are we supposed to take?

In his defence, Hunt could point out that a review of nurse training ‘so that sufficient practical elements are incorporated to ensure that a consistent standard is achieved by all trainees’ was a Francis recommendation (186); but we know from recommendation 185 that in Francis-speak, ‘practical elements’ is just code for ‘less academic’. It seriously looks as if Hunt is hinting that he expects the review to conclude that nurse education should be just that – less academic. But will it?

The review will be headed by Liberal Democrat peer and sometime headteacher, Lord Willis. Lord Willis comes with baggage – in a good way: in 2012 he led what turned out to be a highly sympathetic investigation of nurse education. In the aftermath of Francis, his review was frequently invoked by commentators intent on salvaging some respect for nursing, with many arguing that unlike Francis, Willis ‘found no fault with nurse education’. Unfortunately, this has the disadvantage of not being exactly correct. What Lord Willis did say (repeatedly) was  that his commission ‘did not find any major shortcomings in nursing education that could be held directly responsible for poor practice or the perceived decline in standards of care. Nor…any evidence that degree-level registration was damaging to patient care’.

Compared to Francis, the whole tone of the Willis Report is like a refreshing shower on a hot day. Where Francis is patronising, Willis is frankly admiring of student nurses (‘we were inspired…their bright ideas, commitment and compassion left no doubt that degree-level registration is the right way to go’). Where Francis drones on and on about ‘compassion’, Willis barely mentions it, beyond observing that the ‘the commission saw no evidence to support the view that graduate nurses are less caring or competent than non-graduates, and indeed heard of evidence to the contrary’. Elsewhere, he describes the idea that academic attainment is incompatible with compassion as ‘completely illogical’.

Willis is clear, however, that reform is needed. The difference is that where Francis is punitive, unimaginative and covertly anti-academic, Willis’ clear intention is to give the nursing workforce the tools to liberate its true potential – something which he believes can be achieved only  by degree-level education. Many of the improvements he suggests have as their goal the creation of a research-orientated, academically-credible practice environment, which is seen as essential if  nursing’s professional standing is to be enhanced. Willis also proposes that ‘interprofessional learning must play a key role in continuing professional development’ – an idea that, with its potential for dangerous social mixing, would have Francis reaching for the smelling salts.

None of this is meant to deny the reality of what went on at Stafford Hospital, or to deny that bad nurses exist and should be dealt with. But the fact is that for reasons of background or habit, what was demonstrated by Robert Francis in his Report was his catastrophic failure to understand either nurses or nursing. Lord Willis’ problem is a different one: when he last conducted a review, his master was a nursing organisation, the Royal College of Nursing. This time around, his masters will be the Regulator and a quango. Their agenda may not be the same as the RCN’s, and if the Telegraph is to be believed, the notoriously interfering Jeremy Hunt has already started signalling his expectations. Lord Willis’ challenge will be to resist political pressure and remain true to the admirable vision set out in his earlier work.

I shall write about the details of the review when the Terms of Reference are published in May. In the meantime, if Lord Willis is wondering where to start, he could do worse than this heartbreaking blog: .Student finance definitely needs attention.

For the 2012 Willis Commission report, see:

For the Francis Report, see:

For the Telegraph‘s report on the new review, see:

  1. leninnightingalelenin Nightingale permalink

    The government wishes to deflect attention away from all its cost cutting policies, and the dire consequences that often ensue; but this should not deflect nurses from addressing the poor care given to some patients by a minority of nurses. The aim should be to focus on all aspects that lend themselves to poor patient care .

  2. Thank you for commenting. I agree that poor care is usually the result of a multitude of complex factors. The voluminous back-catalogue of posts on this blog attests to the fact that I have addressed a great many of them right here. This is important because if we accept that nurses enter the profession because they want to care, it follows that poor care must be the result of something that happens after they start their training. The question is – what?
    The point of this post was to argue that the terms of the current debate about nursing have been set by, and enthusiastically endorsed by, people who subscribe to certain self-serving assumptions about class, about women and about women’s work. As one of my Twitter correspondents pointed out yesterday, all recent policy announcements on nurse education – this new review, the ‘pre-degree year as an HCA’ scheme, the ‘apprenticeship degree’ – seem to have a not-so-hidden agenda of undermining the professional basis of nursing. Is the is way to make the workforce feel valued? On an equal footing with their peers? Isn’t it about time nurses stood together and said ‘Enough is enough!’?
    I have never denied that ‘rotten apples’ exist and that they should be dealt with through disciplinary procedures or re-education or a mixture of both. But I think that an over-emphasis on ‘bad’ individuals as the root of nursing’s problems is itself a distraction from the bigger picture. I do not think the answer lies in picking off people one by one; if we do that, we will always be reacting when it is already too late. To prevent poor care from happening in the first place, which is what we all want, we have to look for context.

  3. leninnightingalelenin nightingale permalink

    Thanks, Many assume all nurses are saints and all enter the profession “to care”; this is untrue. Many who care are destroyed by nursing. There are many factors such as gender, power seeking, culture etc. Poor care has been hidden for many years- reflecting what has been happening in such professions as priests. Many do not look wide enough. There are still many, including lecturers, who will not accept poor care is an issue, which leaves bewildered students not knowing what to do in situations. Yes- of course low staffing is a factor.

  4. Your argument seems to be that that many, perhaps most nurses enter the profession for no other reason than to secure an arena for the enactment of their sadistic fantasies, and that poor – if not downright dangerous – care is endemic. If this is true, then it is plainly a scandal of epic proportions, dwarfing even Mid Staffordshire. My question is: what are you doing about it? Because leaving comments on this little blog sure as hell ain’t nowhere near enough!

  5. Barbara Bradbury, Halland Solutions permalink

    I agree that there are many reasons why people enter the nursing profession, just as there are many reasons why people pursue any career. The issue of compassion is widespread and linked, in my opinion, to how society has changed over the last 25 or so years. From Mrs T’s out-of-context quote of ‘there is no such thing as society’, to the current day, we live in a society where people (generally) put themselves first. People want things instantly in this era of immediacy; they don’t readily help others; the younger generation (according to my 19 year-old’s girlfriend) don’t know how to build trusting relationships. I could go on. It is, then, not surprising that people in all professions need to learn how to be compassionate in their adult years, because they are not (generally) learning it through observation and experience from the cradle.

    In tandem with this is the lack of communication skills that is evident at all levels in organisations. People’s inability to handle difficult conversations well – whether these are managers or those who are being managed – leads to poor resolution of issues. Inconsistent leadership and management does not help improve clinical care. The lack of regular performance review and feedback contributes to poor care. How many ward sisters give their team colleagues regular feedback and effectively lead their on-going development? In my experience, not many.

    The nursing profession needs to stop being defensive and justify itself as worthy of being a graduate-entry profession. It needs to be very clear about what it means to be a nurse in the 21st century, and what the professional nurse does and does not do within his/her professional boundaries. Once there is utter clarity on the role a curriculum can be devised that will enable the nurse student to be educated to deliver the role on successful completion of their course. The level of education needed to deliver a nursing role would be apparent. If the primary role of the nurse in the 21st century is to care for people and deliver “bedside nursing” or “basic nursing care” as per the 1970s and 1980s, then the curriculum needs to reflect that. If the main role of the nurse is different to this, then there must be clarity on what it is, so that the curriculum can reflect that instead.

    Unfortunately, it seems to me that nurses still want to “extend their role” and pick up tasks that are usually the province of other professionals. Whether that is in the guise of a surgeon’s assistant, phlebotomist, endoscopist, non-medical prescriber, or anything else – and this is where nursing lets itself down as a profession, I believe. Nurses cannot be proud of a profession that is constantly seeking to work outside of its own boundaries, because the subliminal message is that the profession is not comfortable in its boundaries. As Brysson Whyte once told me when I was talking to her about the nursing and medical professions, “the grass is always greener on the other side of the fence”.

    Work out what it means to be a member of the Nursing Profession in this day and age before entering the profession. Be proud of being a Nurse, and work to be a high-performing Nurse, not escape the profession and be some other profession’s cast off.

    Provide an education that will prepare and equip the modern Nurse to be a great Nurse. If we start here, we might make progress.

  6. Thank you for commenting. I feel a little hesitant to generalise about what young people today ‘are like’. As regular readers of my blog will probably have worked out, I was a teenager in the 1970s. I think today’s teenagers have to be a lot more streetwise and savvy than I ever was, and I admire them for it. Logically, I can see why young people who have had to cope with – for example – cyberbullying might emerge from the experience with a reduced ability to trust, but I am not sure if there is hard evidence to support this supposition.
    I think your point about people wanting everything immediately is actually more relevant to service users than to staff. I can understand this: we now have much higher expectations of customer service, and I think the NHS has often failed to keep up. People nowadays want to be given a time frame for when their scan will happen or when the doctor will visit; a vague ‘sometime today’ or ‘sometime tomorrow’ is no longer good enough. A minority of people become disruptive because they can’t adjust to the ‘communal living’ aspect of hospitals and the fact that sometimes it’s someone else’s problem that has to take priority. I agree that this is something that was rarely seen in days gone by.
    In identifying the need for nursing to define what it really is, I think you have hit on one of the most important, not to say perennial questions. Personally, I am in favour of role extension as long as its aim is to improve and expedite care. In the fast-moving world of modern health-care, where patients’ needs are ever-more complex, it is inevitable that roles will change and expand. What is more important than thinking in terms of mere tasks is, I think, nursing values. We must be clear that we have these at our heart and that they are applicable across the whole spectrum of interventions and activities.
    Where I do agree with you is that nursing needs to take stock. We have sometimes been far too meek about taking on others’ roles. Simply because we are always available, work has been dumped on us with very little discussion, and as a result, we are constantly buffeted by developments outside our control and there is a perceived lack of direction. I think it is this that has weakened our position. What I am thinking about here is not so much clinical roles as administrative duties such as ‘bed management’. Are these really the best use of a trained nurse’s time?

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