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The Opiate of the Profession

June 19, 2014

Is there any problem in the entire Western Hemisphere that can’t be solved by applying the 6Cs? This week alone, the internet has thrilled to the release of Caremakers Song: The Video, and no less august an organ than the Journal of Clinical Nursing has, with apparently straight face, published an editorial on using the 6Cs to write a ‘helpful’ peer review. Coming soon: 6Cs reverse global warming, find a cure for ageing and track down Lord Lucan to a bedsit in Wolverhampton.

In his address to the RCN Congress earlier this week, the newly ennobled Sir Robert Francis told delegates that nursing is in dire need of ‘a unified approach that brings it all together and provides a view that neither government nor the health sector can afford to ignore’. Admittedly, these comments need to be seen within the context of M’Learned Friend’s ongoing ‘agreement to disagree’ with the RCN over his Francis Report recommendation that, as a way of avoiding conflicts of interest, the Royal College should split itself into Trades Union and professional body arms. But even taking that into account, Sir Robert’s is an idea that requires urgent consideration. Don’t crack open the champagne just yet though, because he and I are not entirely at one.

Where we part company (at least to an extent) is his belief, expressed in the same speech, that ‘nurses need to consider how they can realise their true power for the good of their patients through a collective voice which is clearly expressed and organised for the public benefit and not so obviously for the benefit of its members’. Of course, I’ve got no problem with the idea that nurses should work for the good of patients. The trouble is that that can’t happen unless nurses also work on ways of strengthening themselves – their voice, their politics, their knowledge base, their professional identity. Good nursing depends on strong, self-confident nurses.

Which brings me to the 6Cs. I don’t like the 6Cs. Well what I mean is, I don’t dislike them, not as abstract concepts – what decent person could dislike care, compassion, communication, competence, courage and commitment? They’re motherhood and apple pie. But actually that’s my problem – they’re so uncontentious that they’re almost embarrassingly intellectually unchallenging. They might do as a corporate identity (and in my more cynical moments, I do wonder whether the introduction to nursing of a more corporate ‘mission statement’ type mindset is all part of the plan) but as a professional identity, they’re a joke. And not a particularly funny one.

Why do I think this? Well, firstly they’re completely random. In 2013, the current Chief Nursing Officer told an audience at Edge Hill University that the idea for the 6Cs ‘came from me preparing for the Chief Nursing Officer interview, where I needed to present…my vision for nursing, my views, my thoughts about what we needed to do’. No basis in research, debate or political reality then, just someone’s back-of-an-envelope musings. Not good enough.

Secondly, and partly as a result of their origins, the 6Cs are ahistorical and de-contextualised. So yeah, it’s all very nice and very uncontroversial to say that nurses should aspire to be compassionate – we like a bit of compassionate. But the real question is how that compassion can be made resilient in a culture where fear of financial penalties leads to the prioritising patient throughput over everything else? True, adherence to the 6Cs doesn’t preclude nurses from examining the their problems as part of this bigger, more complicated picture, but they do little to encourage it. At their worst, they are the opiate of the profession, legitimising a politically convenient mentality of docility, conformity and acquiescence.

This relentless focus away from the context of care and towards the nurse’s individual qualities is also potentially damaging on a personal level. Nurses already have a Code of Professional Conduct which – rightly – has much to say about the standards of behaviour demanded of them. The advantage of this Code is that it sets a benchmark against which actions can be measured and mitigating circumstances weighed. But the 6Cs seem to impose a whole extra layer of expectation on top of the Code of Conduct – one which cannot be measured against anything except the nurse’s own feelings about him/herself. This isn’t healthy, and in extreme circumstances could lead to psychological distress if the nurse feels that he or she is somehow failing to measure up to goals which may be arbitrary, unachievable and self-defined.

Finally, there is no evidence that implementation of the 6Cs has improved care – and there never could have been, since they were never meant to be evidence-based. Shocking new findings, reported on last week about the care of tracheostomy tubes revealed that ‘more than a quarter of hospitals did not give staff training on dealing with a blocked airway, while only around half offered training on difficult tube changes’. As a result, there were ‘widespread problems…with good practice followed in only around 40% of cases’. Quite apart from the potential for catastrophic outcome in this situation, there seems to have been a failure of at least two of the Cs: competence obviously – but also courage. In 60% of the cases surveyed, good practice was not followed. Why didn’t the nurses who delivered or observed that care speak out? Why was risking patient harm and jeopardising their careers by putting themselves in breach of their own Professional Code preferable to refusing to accept patients for whom they knew they could not provide appropriate care – and continuing to refuse until proper training was provided?

The 6Cs are not a springboard to a strong nursing profession or better patient care – quite the reverse, in fact. In her Edge Hill University lecture, Jane Cummings said that they were designed to be ‘deliberately simple and tangible’. Well, I’m sorry but ‘simple and tangible’ doesn’t do it for me – I’m insulted by it and I think I’m worth more. But if we present ourselves to the world as people who can’t cope with anything beyond the level of ‘simple and tangible’ then we shouldn’t be surprised if that’s how the world treats us. Is it how you want the world to treat you? When you look to your leaders, is it the image you want them to reflect back to you?

Brothers and sisters, the 6Cs are all good things in themselves. Being caring, committed, courageous and all the rest of it – that’s what nursing is all about. The networking aspects of the movement may well set you up with useful contacts for the rest of your career. But ‘warrior for the 6Cs’? Nah – don’t waste your energy. That battle’s won – if it ever was a battle in the first place.

What we urgently need, however, either through the kind of ‘unified approach’ idea floated by Lord Francis or some other channel, is a nursing voice that publicly advocates for a serious, evidence based approach to nursing. And we need it now. The recent dip in our professional popularity – deserved or not – may actually be our opportunity. Rather than simply try to recapture our old beautiful-dutiful image as 6Cs seems designed to do, why not build a new image for the modern era. based on a credible synthesis of evidence, professionalism, political awareness and public engagement. I’m in. Are you?

For the JCN editorial, see:
For Lord Francis’ speech to the RCN, see:
For Jane Cummngs’ sppech at Edge Hill University, see:
For the Nursing Times article on tracheostomy care,see:

For an excellent student view of the 6Cs, see:

  1. I’m in. I was just assigned to teach a certain Nursing Model course – and just cannot see myself regurgitating what brought us to our present state. I want us to agitate and bring the activism back to nursing.

    If we are seeking alliteration – I recently tried to create a political action and advocacy forum – and used 4 Ps: Presence, Partnerships, Policy (assumption is based on evidence) and Politics as headers; we could add a 5th: with and for the Public.

    Keep it real, good luck!

  2. Thank you for commenting. The huge – indeed almost overwhelming – positive reaction to this post is a proof that nurses are thinking for themselves and are ready to move towards to a more nuanced and thoughtful exploration of what it is to nurse. It won’t be a fast or easy journey – a lot of work is required to work out where we want to go and how we want to get there.
    As an old Radical Nurse myself, I’m certainly up for a bit of agitation and activism, but it’s important to remember that not everyone feels comfortable with this, and we need to be inclusive. What is extremely important is that nurses understand the policy background of the situation that we now find ourselves in so that they can decide how to react to it. Whatever the outcome of the next election, the NHS is likely to see many changes in the next few years, and the last thing we want is to nurses simply dragged along in their wake.

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  1. Compassion: semantic satiation? | Digital Reflection

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