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Jane Cummings and Roy Lilley talk about nursing

November 11, 2014

I wish I’d never taken my patented bull shit detector along to last night’s Jane Cummings/Roy Lilley Health Chat. It kept going off the scale and in the end I had to turn it off because the noise was so annoying. The main reason was Roy Lilley. He kept talking bull shit. He just couldn’t shut up about it. On the Care Makers scheme: “It’s just a lot of bull shit, isn’t it, to make the Chief Nurse look like she’s busy?” and on the 6Cs: “the biggest piece of bull shit that we’ve got in the NHS at the moment, which is the 6Cs”. The man’s obsessed!

To her credit, Jane Cummings took it in her stride. Speaking about the 6Cs, the word she used most often was ‘describe’. 6Cs were developed because nurses ‘wanted something simple and memorable that they could use to describe their role’; an aspiring student she spoke to recently told her that she used 6Cs in her interview at the university because ‘they helped me to describe why I want to be a nurse’. 6Cs, the Chief Nursing Officer for England said, were never meant to be evidence-based. Instead, they are a framework that nurses can use when they want to begin conversations about what nursing actually is.

Whether the Cs included in the current list are the right ones is open to debate of course. Roy spoke for many critics when he identified a big question mark over ‘compassion’ – especially ‘in the context of a young nurse with no experience of life and nothing to draw on, who doesn’t understand the subtlety of what compassion is’. A member of the audience asked why ‘culture’ had not been included. Jane replied that the ‘right culture’ was essential for embedding the 6Cs.

But what of current state of nursing culture? Citing the many ‘knackered’ nurses who regularly contact him after coming off a night shift where they were ‘caring for ten thousand patients on their own’, Roy asked whether Care Makers, with their implausibly high-octance enthusiasm and motivation, could possibly represent ‘ordinary nurses’. But Jane insisted that they do. And what’s more, she said, Care Makers act as her eyes and ears on the front line, keeping her in touch with ‘what was going well, and what was going not so well’ in their organisations.

At the heart of the problem is staffing, of course. There aren’t enough nurses. Jane and Roy were in broad agreement that catastrophically poor planning decisions were largely to blame for the current crisis, but when we turned to what to do about it…well, we were off again. Roy’s (playful?) Daily-Mail-Central-Editorials solution of ‘a fast-track to get good-hearted, sensible people into nursing’ seemed guaranteed to got the audience bristling. But on a show of hands, it turned out that only around fifty per cent of the room was convinced that nurses really do require degrees.

You don’t need me to tell you what that means: fifty per cent were not convinced. And these were people sufficiently interested in nursing to come along to an ‘in conversation’ with the CNOE. Hmmmm. How did Jane Cummings react? Regular readers might struggle to believe it, but I’m pleased to report that as far as I’m concerned, she did exactly the right thing. She made the case for degree nurses. ‘You can’ she said ‘be caring, compassionate and competent. In a changing health care environment, you should have a degree’.

In the meantime, the question of how we reconcile rising demand with inadequate nursing numbers remains imperfectly resolved. Roy had some knockabout fun with the National Institute of Health and Care Excellence’s Safe Staffing Guideline (‘Since the Tories closed the Day Centre, I sit at home all day reading guidance’) but his point was deadly serious: ‘there isn’t any real evidence, but one nurse to eight patients looks OK. I can’t believe you signed up to this‘.

Denying that she had ‘signed up’ to anything, Jane admitted that the Safe Staffing Guideline was not built on the firmest of foundations: ‘the evidence is not brilliant from acute care, and is even worse from mental health and learning disability’. Dodging RL’s swipe about how ‘you go to a football match and the number of stewards to spectators is defined in law; you go into hospital, and the number of nurses is defined by the finance department’, and supported by an audience member who said that ‘there is pressure, but that’s where our Director of Nursing takes the lead’, she was clear that it should be nurses – using their professional judgement – who determine staffing levels for their patients. And she was optimistic about the future.

‘It didn’t use to be talked about’ she said. ‘Now we are beginning to put it out there, to publish and describe’. It was a reflection that contrasted strongly with Roy’s earlier survey of the nursing profession: ‘Nursing is at a fulcrum point. Not enough nurses, raking Europe, post-Francis pressure, the finance department’s gonna go barmy and everyone’s gonna get sacked again…nursing is not is a good place’. So where is nursing now? At the start of a journey? Or already at the point of no return? One thing is certain: the next few years are going to be critical.

  1. junegirvin permalink

    That ‘Hands up everyone who thinks nurses need a degree’, should always be followed by ‘Hands up who in this room has a degree’. My guess is correlation.

  2. Lol! Quite agree!

  3. Barbara Bradbury, Halland Solutions permalink

    I don’t agree. Furthermore, at a meeting I was at with nurses this morning, none of them thought that nurses need a degree. All in the room have at least one degree and were CNS nurses, highly qualified and experienced. Everyone agreed that nursing has lost its way and until the profession’s leaders are prepared to admit that we have got some things wrong, it will only get worse.

    One of the things that is fundamentally wrong in my opinion is that students do not need to experience adult nursing. Another is that students are not adequately prepared by their degree programme for what is fundamentally a practical role, Furthermore, because nurse leaders who are role models with excellent practical nursing skills are diminishing rapidly, we will soon have few who actually CAN provide excellent NURSING and, more worryingly, be able to direct excellent nursing practice.

    Being a graduate does not make someone more professional over another. However, I believe the drive to an all-graduate workforce has been the “professionalisation” of nursing. I have always been an advocate of a qualified nursing profession with an underpinning of relevant knowledge. I have also been clear about what is a nurses remit and what is a doctors. If I had wanted to be a doctor, I would have become one – I certainly toyed with the idea and made a deliberate choice.

    Once again, nurses are being prepared to take on the tasks that junior doctors do not have the time for. It used to be doing IVs and other “extended role” tasks. Now it’s “prescribing”, “advanced clinical assessment”, etc. If nurses are going to be members of a “proper profession”, it’s about time that the profession made very clear it’s professional boundaries – what it does and does not do – and not keep on trying to be something else by picking up tasks usually the province of another professional group. As the nurses said this morning, we are not people who need to go around with pads of FP10s and stethoscopes around our necks. We do need to know how to give injections, catheterise people, talk to people skilfully, set up syringe drivers, recognise when patients are deteriorating and take the appropriate action, make patients comfortable……………….

  4. Hi Barbara – thanks for commenting, as ever. I think we have to accept now that nursing is a graduate career. I cannot for the life of me see how this is not a good thing. It gives nurses equality with other professions allied to medicine (no one ever questions whether they should have degrees) and with medicine itself. I’m not going to apologise for prioritising nurses’ professional status here. No other profession would feel the need to do this.
    To be the best nurses we can be, we need in-depth knowledge, well-developed critical faculties and confidence in our ability to express ourselves. Patients will be the winners here. A strong and confident nursing profession is the best way to promote their interests too. I agree with you that the assumption that we will simply take on work that others – from domestics to doctors – don’t fancy doing is harmful to us. But I believe a profession which has been taught to think about what it really wants for itself and to stand up for what it believes in the best defence against this.

  5. There is something that consistently gets overlooked. Nursing degrees were ‘promoted’ as the thing that would save healthcare as the same time as managerialism entered the NHS. The culture of managerialism however is never blamed for the change in ‘care culture’ in the NHS. But degree nurses always are. It is not the fault of being told to look at the bottom line, rather than at level of care that is needed; no it is the fault of having a degree. This strikes me as ridiculous.

    Nursing may have lost its way. But for what the government and society currently think nurses should be doing, I firmly believe a degree is needed. You can argue about whether or not nurses are still being ‘nurses’ or if they are indeed being trained up to do things junior doctors used to do. If this is the case, would you let a junior doctor loose on a patient without a degree? I certainly hope not. So, for what nursing currently is, a degree is needed. The debate should be: is nursing currently what it should be?

  6. Mark Gretton @independent_mg permalink

    Completely agree with Dutchcloggie that it is a very odd argument to state that nurses would be better off without a degree. I can’t think of any other job where people would so confidently state that things would be better if only people were less educated. And it genuinely seems that some nurses are unaware that 50% of nurse education time is spent in practice. Bemusing.

    The argument that ‘nursing has lost its way’ is far from proved too. I started training 30 years ago and if there has been a golden age in that time it’s passed me by. There are too few nurses – that’s the major problem. And this is exacerbated by two many nurse managers who HAVE lost their ways and become well paid bullies who see nothing beyond patient throughput.

    Education can always be improved. But there’s no way that will be achieved by making it less rigorous.

    • And it strikes again ……the battle nurses of ‘today’ have to continually ‘ride’ through. As a first year student (sept 14) with a background in health (HCA, LD Support worker) I am very passionate about starting my degree, have great support and envy many HCP’s within my team and yet we are continually ‘judged’, expected to ‘not become the nurses of the past’ and pinned with a ‘stigma’ that We will be incapable of ‘caring’ or showing compassion, because of our degree interfering ?!? I personally do not wish to be a nurse of the past, I will be a nurse of the future. I will not follow tradition, or act upon myths. If it works and I know why it works then I’ll practice it! I will personally grow, build self confidence and my patients will benefit from my abilities, and seek comfort from the knowledge of having a well educated nurse…..see there is no break when I say that ‘well educated nurse’, nowhere in that sentence am I saying, ‘a better nurse’! And yet repeatedly I hear concerns from nurses; of how student nurses of today will never cope’.
      Maybe, just maybe give us the tools to work with, the instruction manual to follow & our coping mechanisms will flourish.
      Why do we have to prove our worth, it seems to be accepted we have to play ignorance to our degree, not mention our assignments and in no uncertain terms should our PAD appear. Why?…
      Working collaboratively as the professionals we ALL are (or will become) will ensure ‘best possible patient outcomes are achieved’ surely this is the art of giving care.
      How can we work in unison if we are fighting to gain acceptance?
      This has been wrote with a fire in my heart, that’s because I am passionate about my profession; however I gain that title is besides the point.

      • I will now also add; where is the evidence that ‘degree’ nurses are negligent in practice ? As although I haven’t heard this said, it could be assumed this is the impression being made. The NMC hearings available for clinical negligence /not abiding by sections of the code are public. Are these hearings higher for professionals with a degree ?. Is qualitative patient feedback reflective of this too?.
        I must find time to research this and gain some evidence, so too should HCP’s with any doubt for professional conduct !

  7. Thanks for for your heartfelt comments. Your description of how you ‘repeatedly…hear concerns from nurses of how student nurses of today will never cope’ is a problem that comes up a lot and is a sad reflection on nursing culture.
    The move to ‘professionalise’ nursing has sometimes been criticised by feminist writers on the grounds that it reproduces a masculine model of what a profession should be within the ranks of a mainly female workforce – who are thereby denied the opportunity to formulate a model based on their own values. I have a lot of sympathy with this view, but it overlooks an important fact: much of ‘traditional’ nursing culture is already based on macho discourse: the idea that status and admiration are derived from toughness, outspokenness, staying late and a sort of gung-ho practicality. It’s also a world where little value is placed on intellectual achievement.
    In some ways, it would be wrong to be too hard on this mindset. It developed as a survival mechanism, a counter-narrative to a medical culture that would have preferred it not to exist – and it has elements of class-based self-defence. But it is inappropriate to today’s nursing. Reversing it, and creating a nursing culture that prizes knowledge is one of our most urgent tasks.
    You might also be interested in this recent blog post from Britains Nurses:

  8. Wish I could have attended the meeting.

    On the issue of whether nurses need degrees. I already have a degree, and don’t think nurses need to have a degree. The difference between the diploma and the degree was more time in the class room, and writing a 10,000 word dissertation at the end. Does that necessarily prepare people better for a role? I agree the extra time in the classroom might (if those classes aren’t just lectures of 100+ people rebranded as classes), but the dissertation seems superfluous.

    What is much more important is continuing education in practice. Training budgets are under pressure, and not many of the wards I’ve worked on have a good educating/learning culture, or they simply don’t have the time.

    What would be better than pushing people onto the degree course would be for NHS trusts to use the resources they already have. Release nurses from the wards each week to attend lectures by the many competent nursing and medical staff they already employ to develop their nurses knowledge further. Coupled with protected time at least each week, but preferably each shift where nurses could sit down together and discuss issues on the ward or teach each other would improve skills and provide the continuing education nurses need.

    One ward I trained on, which operated a 3 shift pattern (early, late and night shift) used the 3 hour overlap each day shift to free nurses to run teaching sessions every day. A staff nurse (diploma or degree level) gave a talk on a different subject over lunch, whether it was taking observations, diabetes management, A&P or something else. Nurses on that ward are always regarded as the best trained in the hospital, and its done using the wards resources, albeit they have good staffing levels.

    That is the key, if you improve staffing you give people more time for learning and education and you develop better nurses.

    As for where nursing is going, I think the government is just trying to keep a lid on things till they’ve got their whole NHS privatisation plan in place. Nursing is working more and more in a market based system. Patient throughout is encouraged to meet targets and secure tariffs, and actual patient need is discounted. The 6 Cs are just the appearance of doing something, and something to remember for your next job interview. I tend to think nurses need to start collectively organising, and setting the agenda. Campaigning to democratise wards, to take power out of the nursing hierarchy and put it back in the hands of frontline nurses so they can decide how best to work to meet patient need would go a long way to improving morale and creating a set of nurse values which more people could agree with, and that didn’t just look like window dressing.

    • Interesting point about staff nurses giving talks to other nurses. I can see the merit in that but how do you know that what this nurse says is right or the most recent knowledge? I work with very experienced nurses on my placement all the time and sometimes hear them say things they have learned in practice that are in actual fact simply wrong. Also, how would you vet who is ‘knowledgeable’ enough to give a talk? Not every staff nurse is great. Some are awesome, some are OK and some are a bit rubbish. Only those with more than 5 years experience? Or 6? How would you guarantee that what they say is right?

      Your idea has merit but I would not release nurses to get training from nurses and doctors who already work at the hospital. I would like to see every nurse having 2 days (or more?) every month to attend lectures at university. Either about updated theory or about new ways of performing certain clinical skills. I feel that just because you have been doing something a long time is not a guarantee that you are doing it right. Remember, not that many years ago, experienced nurses told young nurses that standing patients next to their bed and blowing O2 at their bottoms was the way to prevent pressure ulcers. After all, they had been doing that for years and after a few minutes of blowing O2 at their bottoms, the redness went away….. Surely that proved the O2 was working…..

  9. I agree that the key to changing nursing culture lies in ensuring that education, updates, research and reflection are all normal parts of the work experience. But because of the excessive demands being placed on nurses at the moment, I can see little prospect of this happening. Supposing it could happen, we do need to be sure that those delivering education sessions are qualified to do so and are delivering correct information. If they are ward-based, we also need to make sure they have paid time to prepare their material.

  10. As a mere patient, I am amazed that the degree thing is even an issue after all this time. While you can’t learn caring from a book, it’s perfectly obvious that you can’t readily acquire the in-depth, systematic knowledge needed to underpin effective caring, in an ad-hoc, let’s-see-what-today-throws-at-us manner. Nursing is a profession and as well as practical experience, nurses should have professional status and qualifications, whether they ‘need’ them or not. End of.

    What worries me a lot more is the non-professionalisation of HCAs, who provide a great deal of what the patient public thinks of as ‘bedside nursing care’ and, from my observation, perform a wide range of delegated clinical tasks, some of them critical to patient welfare and even patient survival. Yet they have no overall, benchmarked and consistent training, supervision or occupational feedback, despite being placed where they may encounter significant risk and be blamed for mishaps (since they cannot be held professionally accountable). It does not seem fair either to patients or to the HCAs.

    A far more productive conversation, from a patient perspective, might be one about how nursing proposes to train and support HCAs, with a view to welcoming (and I do mean welcoming, not ‘affording grudging third-class entry for’) them into the professional fold.

    It does indeed, as Barbara suggests, mean that nursing would need to be a lot clearer about its role and boundaries. However, boundaries do not have to be static. Outlining the dynamic boundaries of 21st century nursing would doubtless generate a great deal of Moebius discussion. It might be helpful to chuck the “Do nurses need degrees?” question right out of the loop once and for all.

  11. Hi Kara, thanks for commenting. I think the reason why the debate about nursing degrees won’t go away is that the popular press won’t let it. The Daily Mail has let it go a bit in recent weeks, but only because it has lots of migrant ‘invader’ stories to work itself into a lather about. Their basic position is that they don’t like educated women, but because they can’t say that, they talk about educated nurses instead. It’s depressing that many nurses seem to agree with them.

    The issue of consistent standards for HCAs is being addressed through the new Care Certificate. This is a modification of the ‘Certificate of Fundamental Care’ that was proposed by the post-Francis Cavendish Review. However, as it applies only to new entrants to HCA roles, it will be many years before everyone has received this training, so variations in skills and knowledge will persist for a long time to come.

    The question of registration for HCAs, is, I think, a separate (but related) issue. Registering everyone currently working as a HCA in the UK would indeed be a bureaucratic nightmare. The government is not simply coming up with a lame excuse when it says this. In part, of course, it’s because pay and conditions, especially in the private and community sectors, is so poor that people quickly move on or drop in and out of this type of employment. But I think that with the introduction of the Care Certificate, there may have been an opportunity to at least begin the process, which has now been lost. It’s a fact that HCAs (and even more so also assistant practitioners) are now undertaking duties that just a few years ago would have been the sole preserve of a registered nurse. From a patient perspective, I can see that that is worrying.

    The underlying situation is that patient numbers are increasing and technology is moving on. For this reason, as you rightly say, professional boundaries are constantly being re-drawn. Doctors are also having to face up to this with the new ‘Assistant (Medical) Practitioner role, and some don’t seem too keen on the idea of ceding professional ground:

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