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Two Tribes

January 27, 2015

During the ‘A&E crisis’ of early January, the Guardian Health Professionals’ Network was awash with articles by staff, including nurses, whose working lives encompass the harsh realities of manning the NHS front door. Most of them made for very difficult reading, especially this one by an anonymous twenty-something nurse who feared that unmanageable workloads, unsympathetic bosses and lack of workplace support mechanisms had already set him or her on the road to burnout. But then something slightly different appeared.

This time, the writer was another anonymous A&E nurse, undoubtedly grappling with many of the same problems as the first contributor. But while acknowledging severe systemic strains, he or she maintained that working in A&E is ‘a privilege’, and that most patients continue to receive a high standard of care. And this was no head-in-sand idealist: there was enough political savvy here to know that ‘we, and the failings of the current system, are being used as a tool in an ideological war’. The author’s warning was that staff who add to and acquiesce in the ‘broken NHS’ rhetoric are putting weapons into the hands of those whose fight is to destroy our health service.


Striking a balance between celebrating and further developing the brilliance of fantastic nurses – while at the same time recognising the often extraordinarily challenging environment in which they are working, is one that goes to the heart of British nursing. To borrow an idea from post-modernism, what we seem to have now are two competing discourses. In one corner are the ‘real-worlders’ – staff-room bores from up and down the land, giving anyone who’ll listen the inside track on how ‘managers haven’t got a clue and the only answer is more staff’. In the other are the ‘compassionate crusaders’ with their ‘love conquers all’ road show (no doubt played out against a power ballad soundtrack).

Neither of these is sustainable in the long term. Whatever the entirely justified complaints of the ‘real-worlders’, their non-negotiable demands for extra staff are not going to be met – for the simple reason that large reserves of so-far unutilised nurses just don’t exist. And as for the populist notion that ‘managers haven’t got a clue’ – well the truth is that solutions to workplace pressures are all going to be management solutions. They can only come from service reconfiguration, re-drawing of professional boundaries and evidence-based interventions to promote staff well being. If nurses want to be part of this, they have to forego the comfort of standing back and blaming everyone else, and get involved. And managers have to welcome their involvement.

For the the ‘compassionate crusaders’, involvement is not an issue. They have totally grasped that social media is the tool that can connect them with each other and enable the creation of something akin to a social movement within the profession. Even better – thanks to the refreshingly democratic nature of the medium, anyone can join in. Nursing threads on Twitter are bursting with bright, motivated nurses and nursing students who have found their voice and are using it to talk nursing. For future of the profession, it’s an encouraging development and one that’s to be applauded. But there are pitfalls.

For one thing, enthusiasm on its own is not enough. To shape the debate, it needs to be linked to an agenda or purpose. Without this, there can be no conclusions and all we are left with is a kind of never-ending screen-grab-assisted motivational speech. Would that be anyone’s first choice for a fun evening? More worryingly, because social media lacks any kind of adjudication or moderation, it creates and enforces its own etiquette and despite its purported democracy, there is a risk that some things become unsayable. And heightened sensitivities around ‘compassion’ mean that it is just the kind of concept that may fall into this category.

To be clear, the questions are not about whether compassion is a good thing; plainly, in its unsullied, dictionary-definition form, it is a good thing. Rather, the questions are to do what we might term applied compassion: the usefulness and achievability of compassion in clinical practice, and – assuming we do believe it to be both useful and achievable – how we then promote and sustain it. We also need to ask what an excessive focus on this one area tells us about our wider culture – and whether it blinds us to other equally important issues.

Last Monday, I was lucky enough to attend a superb conference at the University of Worcester where these questions were debated by both academics and representatives of service and education. The morning session in particular was a stimulating and energizing intellectual cut-and-thrust, and I’m sure that everyone in the audience went to lunch with lots to think about. I certainly did.

For me, however, some of the most interesting revelations came from the afternoon session. What became clear was that despite the strident post-Francis rhetoric – both in the media and from central government – on the character defects of individual ‘uncompassionate’ nurses, the focus in Trusts and in educational establishments, has quietly turned to the environment of care: what it looks like and how it can help to sustain compassionate values over a whole career.

To return to the ‘two tribes’ described above – this is an important point for both of them. For the ‘real-worlders’, it is evidence that – however haltingly, however imperfectly – the realisation that that staff well being is inextricably linked to patient well being has begun to sink in. For the ‘compassion crusaders’ it should serve as notice that ‘compassion’ is not a simple concept; and by insisting that everyone accept it as a given and refusing to explore, we risk cutting ourselves off from important intellectual currants and, even worse, creating a new version of the toxic unable-to-question culture that is said to have spawned Mid-Staffs.

By showing an interest in finding solutions, nurses at all levels can also parry the accusation that complaining about the NHS simply serves to undermine it. But we can only find those solutions if we talk to each other.

  1. Barbara Bradbury, Halland Solutions permalink

    Absolutely! The more we play the “poor me” card, the more we fall into the hands of the negative press reporters who would have us believe that the NHS is irreparably damaged and should be taken out of the public domain. We run the risk that a self fulfilling prophecy is the outcome.
    There is no doubt that these are difficult times for all those who work in the health service. And, I am very concerned about the standard of management and leadership as I see too little being done WELL. There is a situation where too many graduates from the graduate trainee management scheme are being promoted to senior roles too early in their careers. They are inexperienced and do not consolidate their learning before moving up the managerial scale, taking their inexperience with them.There is also an abundance of interims, who have a different agenda to those in substantive posts. Together, with a high reliance on agency staff filling clinical vacancies, the health service is certainly stretched. We must be careful to avoid having a workforce that is heavily dominated by inexperienced managers who will perpetuate the problems that they create. Also, large numbers of interims and agency health care professionals who cost the service much more than people employed in substantive roles. We should be working hard to ensure that our NHS is attractive to employees, not somewhere to leave and then go back as an agency because it’s easier to avoid chaos, unpleasantness and poor direction.
    Furthermore, don’t imagine it’s any better in the private system. It, too, has its difficulties.

  2. Hi Barbara. Thanks, as ever, for commenting. I don’t know enough (for which read ‘any’) NHS managers to make any meaningful observations about them. I may be wrong, but I tend to think of them as people who work in offices and visit the clinical areas only occasionally. It’s a situation that can’t fail to perpetuate barriers and an unhelpful ‘us and them’ mentality. This is especially true when the service reconfiguration prefigured by the Five Year Forward view is crying out for nurses to come forward with their ideas and be a part of it.
    All I can say is that I was very interested in the comments from senior managers at the bottom of the HSJ piece about the suspension of this week’s strike action. The new pay offer that unions will put to their members includes a clause ‘that staff earning more than £40,558 will not receive an increment rise in April this year’ – which certainly seemed to prompt a awful lot of ‘poor me’ reactions from those to whom it applies!

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