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W(h)ither Compassion?

April 29, 2014

Why is nursing the only profession where a less educated workforce is openly promoted as a good thing? Think about it. Would anyone ever suggest that doctors need less theoretical grounding before being let loose on patients? Or that ownership of a box of Lego and a complete set of Grand Designs DVDs series 1-12 is equivalent in all but name to five years of studying architecture? I don’t think so.

More contentious perhaps is the spread of degree preparation to those occupations where it hasn’t traditionally been thought necessary –  golf course management is the example usually trundled out. Nevertheless, it’s a development that was applauded by David Cameron in a speech last October. “For years” he told an audience in Oxford “there’s been a snobbery in this country about some degrees…we’re now going to find out which degrees really benefit people. It will get rid of that snobbery”.

And yet despite all this, large sections of the British media still consider it quite acceptable not just to question the need for nurses to have degrees, but to drop broad hints that academic formation is actively harmful to the fostering of compassionate instincts; and all recent government policy pronouncements on nurse education – the ‘year as health care assistant’ scheme, the apprenticeship degree and the new review of nurse education – seem to have at their heart a stealth agenda of undermining our professional basis.

The recent Telegraph article in which Jeremy Hunt again linked the proposed review to a perceived compassion deficit in nursing seems to have come as the last straw. Loud groans of ‘not again!’ were audible even from normally staunchly apolitical corners of the nursing Twitterverse. But if we want to challenge the poisonous rhetoric about nurse education and compassion, we have to understand the utterly spurious nature of its origins.

On my blog, I have attributed these to variously: class and gender biases of the British ruling elite; wider societal anxiety about the threats posed by educated women; and political expediency associated with distracting the public from other potentially unpopular politically-motivated NHS  changes. This week, I want to draw your attention to something new. I’m going to call it a ‘genetic mutation’. I am indebted to an an anonymous commenter on who last week pinpointed its exact location inside the DNA of the Francis Report. Its appearance changed the terms of the debate. Permanently.

To start with the comment. The commenter said: “I want to know where…this idea that compassion was lacking in nurse education came from. The Francis Report says it bases it on anecdotal evidence from a seminar, but nothing in the public record of that seminar seems to substantiate the claims”. This prompted me to explore further. What I found was…very interesting.

The public record of the nursing seminar devotes about a page and a half to ‘Training and Development’. ‘Compassion’ is not mentioned. Instead, there is clear consensus around the view that inconsistent placement experience is the biggest problem. In its submission, the Nursing and Midwifery Council is quoted as saying that ‘teaching in universities is focusing on the right things – it is the quality of practical experience that needs to be addressed’. ‘This is a point’ the record gnomically observes ‘that many participants echoed’.

The solution is unambiguous: ‘To improve the practical therapeutic and training skills of nurses during the training period, universities and Trusts need to establish closer connections so they can plan the combination of academic and practical work more effectively. They should consider re-establishing the role of clinical tutors who are responsible for the teaching of practical nursing skills’ (p41).

Turning to Francis itself however, we find that the focus has unaccountably switched from quality to quantity: ‘At both the Inquiry seminars and during the hospital visits undertaken, the Inquiry was told of concerns that today’s nursing training contains an inadequate quantity of practical experience at an early stage’ (para 23.56). So what students need is not better placements, but the opportunity to spend more time on potentially rubbish ones. Am I alone in finding this perverse?

It is not until the final distillation of Francis’ thoughts on nurse education (‘There should be 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) that compassion makes an appearance. But quite how it is supposed to be instilled by spending more time on placements that Francis has already been told are of worryingly variable quality is left unclear.

What is clear however is that there is a remarkable degree of congruence between the views expressed at the seminar and the findings of the first Willis Review of nurse education, particularly recommendation 3.3 which stated that ‘Close, effective collaboration between universities and practice settings should be enhanced through joint appointments’. So much agreement. So little mention of compassion.

Personally, I’m not a fan of compassion as a guiding principle in nursing. I think kindness, respect, empathy and good listening and communication skills are more useful and more achievable in professional relationships. That’s not to say that I never feel compassion for patients; I do. It’s like a welling-up inside and an urge (sometimes acted on, sometimes not) to give a big warm hug. But it’s something that’s spontaneous, usually brief, and not amenable to being turned on and off by diktat. And such heightened emotion is neither helpful or desirable in most work situations.

On the other hand, I don’t want to lose compassion. I want it to remain on the menu, savoured all the more for not being chosen very often. But in the current dispensation, compassion is at risk. On one side we have the politicians, ironically deploying compassion as a stick to beat nurses and devaluing it with constant hints that education inhibits its development. On the other we have nurses themselves, and their masochistic displays of devotion to a god that can’t deliver. The result is that is that a small but growing number of commentators are already branding compassion as nothing more than a ‘buzzword’.

The solution for all sides – politicians and professionals –  is to de-escalate. Take the heat out. Stop talking about compassion and insist instead on facts and evidence. The solution is emphatically NOT to junk compassion and start talking instead (as I have seen seriously suggested) about love. These strong emotions traditionally have no place in nursing and there are good reasons for that. They are difficult to control and if you legitimate one, you have no logical reason not to legitimate others. Anger in professional relationships anyone?

British nursing has been set back at least a couple of decades by the whole ‘compassion agenda’. It didn’t start with the Francis Report, but it certainly gathered impetus there. If anyone on the inside would like to spill the beans on how that catastrophic genetic mutation came about, give me a call. Confidentiality guaranteed.

  1. junegirvin permalink

    Excellent analysis. This is a really helpful contribution to the ongoing debate. Why don’t you submit something similar to the Guardian health professional blog? Or their education blog?
    I am going to RT this at regular intervals through out the day.

  2. Thank you very much! I have submitted ideas to the Guardian, but no dice 😦

  3. There is a difference in the way Doctors and nurses are educated, Doctors get their theoretical education, then they have to learn how to do the job under close supervision, nurses get qualified then are let loose on the public, with very little, in comparison to traditional nursing, practical experience. The majority of nursing is physical whereas Doctors practice is generally not physical. To remotely consider the educational needs of Doctors and nurses as being equal is rather simplistic, indeed other than Vetinarians or dentists I can’t think of any profession which could be related in this manner.

    The traditional nurse training worked, no one can deny that or indeed would try to say it didn’t, it also got rid of people who thought they wanted to be nurses, but in fact were not suitable early on in the training structure. Following the initial training Nurse could and many did then do degrees to improve their knowledge. Under the current system, students can do three years and then as many do not bother to register to be able to use the degree, or quickly decide it wasn’t what they really wanted, the waste of resources involved in this wastage is far higher than it was. I find the rather childlike ideation that you need to be capable of regurgitating what someone has written and get a degree to be able to supply superior care rather strange, and doubt if there is any evidence to prove any improvement in the level of care at all, indeed given the amount of complaints about nursing care these days it would appear to be the opposite effect to what was envisaged.

    • As many do not bother to register? Really? In the cohort above me all are registered and 99% have got jobs.

      • We can all give that sort of comment on things, the group that qualified before me when I did my Psyche training didn’t get any jobs when they qualified, our had 100% available, a similar thing happened when I did my General training. the fact is that the statistics show the cohort before you, how many were in it BTW, is very much an aberration these days.

        Grumbling Appendix replies: People are obviously having different experiences here. Perhaps further comment on this could focus on hard evidence/figures rather than anecdote.

  4. Thank you for commenting. I don’t agree with much of what you have said, but I imagine you weren’t expecting me to. The contrast you draw between doctors and their ‘theoretical education’ and nurses’ need for ‘practical experience’ implies that you think the latter is more appropriate for nurses. Why? Because getting a degree is mostly about ‘regurgitating what someone has written’? So why did anyone ever think it was the right way to train doctors? Or is the regurgitation element something that’s unique to nursing degrees?
    When you say that ‘traditional nurse training worked’, I wonder what you mean? It turned out nurses who knew their place and were properly deferential? I would agree that there are some wonderful nurses who trained by the apprenticeship route. But the pre-degree days were no golden age – I did my own training back then, so I should know. Since those times, health care has moved on enormously – it’s now much faster and far more complex. Public attitudes have moved on too – where people were once meek and accepting, they are now upfront and demanding. I’m not saying they’re wrong to be demanding – but dealing with it takes skill.
    A degree should equip students to think critically and act autonomously. If you were seriously ill, wouldn’t you prefer to be looked after by a nurse who can make informed and effective judgements? Research suggests your ultimate outcome is likely to be better. Of course nurses and all other health care professionals should be kind, understanding, good communicators and highly competant. It’s a great mistake to think that education means they will no longer be any of these things- but it’s a mistake the popular press encourages you to make, and Jeremy Hunt does little to challenge it.
    As to your claims that many new graduates ‘do not bother to register’ or ‘quickly decide [nursing] wasn’t for them’ – I have no knowledge of this. Perhaps you could substantiate?

  5. Barbara Bradbury, Halland Solutions permalink

    I agree with Barry Davies’ comments. I also agree that the emphasis on compassion is ill-founded and unhelpful. However, I don’t think that the nursing agenda has been set back by this. Nurses lack coherence regarding their own professional role boundaries and, whilst this continues, they will not be able to agree what nurses need with respect to education and training.

  6. Thank you. I am hoping that the whole ‘compassion thing’ will go away soon, and be replaced by something more constructive. I agree that the definition of professional boundaries is an area that needs attention. It is difficult to argue your corner if there’s no clear consensus about where your corner is located.

  7. Great blog, it is more than the compassion debate, nursing as the NHS are used as a political football time and time again. There is nothing more the media love than discussing this very issue – too posh to wash, etc. Nurses and nursing are wheeled out by government and the media when suits or when an agenda is being pursued…. The reaction to Francis proved this, the vast majority of nurses are not uncaring or lacking in compassion, many other factors must be taken into account.

  8. Thanks for commenting. In order to oppose official and media rhetoric, we have to understand the larger forces that motivate it. This is a subject on which I have written extensively, and I hope people have found it useful and interesting.

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