On being paid to breastfeed

There’s been a fair bit of coverage today of this story that a trial is beginning in a couple of deprived areas of Yorkshire of paying new mothers up to £200 in shopping vouchers to try and encourage them to breastfeed for 6 months, with a view to extending the scheme if it proves successful. Breastfeeding is a subject currently high up in my consciousness, as I have just started maternity leave (no baby as yet though! :) ) and do intend if possible to breastfeed if I can. I have really mixed feelings about this initiative.

In my last post I ranted about people constantly referring to breastfeeding as “free”. As I said there, it is only “free” in the sense that money doesn’t change hands the way it would if milk was bought and sold. The demands on a woman’s (and wider family’s) time, work, health, etc are not to be sniffed at, and there are plenty of economic implications. Breastfeeding doesn’t always work out quickly, sometimes it can take several weeks to get properly established, and in that time the woman might experience pain, stress, and complications requiring help from health staff and/or medication – all of which cost money (OK not to the woman directly, but they have to be paid for somehow and it is the health services that pick up the tab). Even if it does work out, for someone exclusively breastfeeding the physical costs of feeding every few hours day and night are not to be taken lightly. And on return to work, if you are still feeding whilst the baby is in childcare, there is a cost to the employer of providing facilities for expressing breastmilk (a private room and a fridge, as well as time).

So part of me kind of welcomes the monetary aspect of this – I don’t necessarily think it is a bad thing that the financial aspects of breastfeeding are explored and discussed. Having said that, I suspect that would be an unintentional outcome of the initiative – I don’t think the vouchers are there to extend the debate, just to simply act as an incentive. Incentives in themselves aren’t necessarily a bad thing – it would be great if breastfeeding rates could improve, and nationwide they appear to be quite stubbornly not growing currently. However, I am not convinced at all that this is the way to go.

I have a number of concerns. One particular red flag in the BBC article linked to above was the sentence “Midwives and health visitors will be asked to verify whether the women are breastfeeding.” It reminded me of the concerns that lecturers had/have in higher education about having to verify whether foreign students are attending lectures and reporting back; if we had wanted a police role we would have trained to be police officers, not nurses/lecturers. As it is, health visitors are often already seen as the breastfeeding police (and not in a good way! – I think a common perception is that we will bang on about breastfeeding regardless of whether the woman wants to continue or not, and are unsupportive to families who choose to formula feed), and I don’t think that this will particularly help the therapeutic relationship that we all strive to build with families. I want to offer support to families to feed in the way they choose, not police whether they are meeting the criteria for a particular benefit/incentive. Also, this scheme does nothing to address the gaps in service which might lead to women not being supported – yes by all means give vouchers, but if there are not enough appropriately trained health professionals to offer support when the going is tough, the vouchers aren’t going to solve breastfeeding issues.

There is also the class issue to consider – this initiative is currently aimed at a more deprived, lower socio-economic area, with the assumption appearing to be that money is therefore an appropriate incentive to offer. There are plenty of so-called working-class women who breastfeed, and plenty of affluent women who choose not to, and I worry that the use of monetary incentives in deprived areas could act in a way to stereotype further the people who live there. I think that it would be better to provide more funding to train more health professionals to high standards in the full range of infant feeding, for all families who want/need that support, and provide the ongoing support needed instead of simply being the Breastfeeding Police monitoring who’s claiming the money.

The politics of infant feeding

I read a couple of articles about breastfeeding recently which got me thinking about infant feeding more generally, and the messages that society and professionals give about it. This is not a post detailing the benefits of breastfeeding (although I happen to think breastfeeding is great when it works, and would be my personal choice if possible, it’s not always that simple, and there are plenty of other places where that is debated), but is more about the judgment that other people make on women’s choices.

First up, this News Shopper article from Bromley, about a breastfeeding mother who was made by a Job Centre worker to leave the meeting she was in because she was breastfeeding. I don’t have much to say about the actual story – I happen to think that the Job Centre worker was absolutely out of order, and if they found breastfeeding really that disgusting they should have left and found someone (a manager?) who could continue the meeting. What I found more interesting/depressing were the comments that follow the article. There is a lot of class judgment being expressed (the mother is on benefits, and has 5 children), but also a lot of pro/anti-breastfeeding posts – asking if she’s “one of these militant breastfeeders, that whip it out and stick it on, with the aim of shocking as many people as possible”, and referring to her as “a breeding machine” and “an exhibitionist”. One of the comments says that given the circumstances she should have expressed her milk into a bottle in advance (as if it were always that simple), and another asks if those supporting and promoting breastfeeding in public are the same people objecting to the objectification of women and the display of their breasts (for example on Page 3) in the media (as if taking these two stances somehow makes the person hypocritical, as breasts in public – whether for feeding or for titillation – are the same thing).

Quite apart from the obvious sexist and classist judgments being made here, what on earth gives people the right to pass comment on a mother’s choice of how to feed her baby in public? I am aware of people who wanted to breastfeed but for various reasons were unable, who have also faced such judgment and disapproval when they took the bottle out to feed their baby, so it is not just breastfeeding women who deal with this issue. I hope when I was health visiting that I was supportive of people’s choices and not judgmental – whilst there are certain milks on the market that I think are less than optimum, and I wouldn’t have a problem suggesting more appropriate milks for a young child, choices about which milk to feed a child are about so much more than the milk, personal hopes or beliefs about the milk’s effects, or financial issues. Family habits/pressures, societal dis/approval, advertising messages and professional messages all play their part, and I do think that as both a health professional, researcher, woman and member of the general public I need to reflect on the messages I give (verbally and non-verbally) conveying my dis/approval, judgments or opinions, and take real care to be sensitive and non-judgmental.

Secondly, I saw this post retweeted a few times a few weeks ago, in response to this New York Times opinion piece by a columnist called Nick Kristof about a young mother in Mali he introduced to a doctor and who taught her to breastfeed, thus allegedly saving the baby’s life. The blog post critiques Kristof’s column beautifully, and I couldn’t really add much to her points (and of course I am glad that the child in the story appeared to thrive, although the quick recovery does strike me as a bit too Hollywood), but I do want to reiterate what she says about the economics of breastfeeding – it is only free in the sense that money doesn’t (usually) have to change hands in order to get the milk. I’ve worked with enough families in my time where breastfeeding has taken weeks of hard work and a hell of a lot of lost sleep to be established (or not, in some cases) to know that it isn’t a bed of roses, and doesn’t come without cost, whether that be to the mother’s time, relationships, job, ability to plan activities in public (see case above) and all the rest of it. Proclaiming it as “free”, no-cost, easy, and the obvious choice, makes no acknowledgement of all the myriad of factors which can affect whether it happens or not, or that it is the woman that bears the bulk of the burden. Again, whether approving or disapproving of breastfeeding, it is a woman’s choice which is judged by outsiders, and again as a health care professional I need to check myself and make sure that I’m not just adding to the chorus of dis/approval but actually enabling women to make the best choice for them and their baby/ies.

I’m not sure that the professional focus on “breast is best” is always helpful in the debate. As I started to write this post I saw a BBC article on twitter, about a health authority’s bid in England to tender for an infant feeding service. I do think that such services are really helpful, and it’s great if women who want to breastfeed have access to professional support rather than being left to sink or swim on their own. But Dr Ellie Lee’s concerns expressed in that BBC piece need to be heeded – the problem with a lot of health education/professional messages are that they are a list of benefits, regardless of the evidence, and any attempts to find out more about the evidence-base are shouted down or assumed to be dangerous and anti-breastfeeding. I don’t think the health services do themselves any favours by shouting about claims for breastfeeding, some of which have more questionable evidence bases than others, and ultimately the impact will be in increased cynicism and reluctance to try, and increased suspicion of those of us keen to promote breastfeeding where it is possible. Surely it can’t be that difficult for us health professionals to be more nuanced and balanced, more academically critical of the claims of evidence, and less judgmental of women and their choices?

Nurses are …

A couple of weeks ago on twitter someone I follow (a historian) tweeted that if you type “historians are” into a google search box you get a brilliant poem:

Historians are
Historians are dangerous people
Historians are past caring
Historians are writers
Historians are prophets in reverse.

I rather liked that, so I thought I’d type in “nurses are” and see what came up.

Nurses are
Nurses are stupid
Nurses are mean
Nurses are great
Nurses are us
Nurses are patient advocates
Nurses are heroes
Nurses are
Nurses are special
Nurses are better than doctors
Nurses are mean to each other.

I have to say, that left me with quite a bittersweet feeling. Along with the stereotypes (heroes/special – though I was amazed “angels” didn’t make an appearance!) there’s plenty to be sad about here, if these reflect the most often-searched phrases.

It’s got me musing on what “nurses are” to me. As someone who is a bit ‘in-between’ nursing-wise at the moment (still registered, not practising although working in health research) Lynne Stobbart‘s recent blog post certainly resonated with me. I can’t quite put my finger one one word or phrase which sums up for me what nursing is and what it means to me and who I am – yet – but without wanting to get too metaphysical about it I do think there’s something ontological there, it’s more than just what I did. It’s something I’ll be musing about for a while I think.

What do you (especially the nurses, although I’m really interested in other views too) think of when confronted with the phrase “nurses are…”?

Book review

Last year I wrote a review essay for Europe-Asia Studies, which is the journal produced by the department where I did my PhD. That review is now (finally) online first (not sure when it’s going to be in a print version). I thoroughly enjoyed both reading the two books and writing the essay – I’d highly recommend both books (“Democracy Building and Civil Society in Post-Soviet Armenia” by Armine Ishkanian, and “Women’s Social Activism in the New Ukraine: Development and the Politics of Differentiation” by Sarah D. Phillips) if you are interested in development issues particularly as they pertain to civil society – although both set in former Soviet countries, a lot of the issues raised are extremely relevant to development studies more widely.

Although my PhD was not a development studies PhD, and I was not looking specifically (or rather exclusively) at civil society issues, it was something the PhD touched upon as several of my respondents were from civil society organisations and reliant on donor funding in order to provide their services and to carry on functioning. I certainly found myself nodding in recognition at several points in both books. In some senses they were a bit depressing – the findings from both studies seem to be that little has changed or been learnt in how many years of development funding and civil society promotion – but as thorough and thoughtful studies which go into enormous detail of both macro-level (Ishkanian) and micro-level (Phillips) experiences of activists and organisations, they are both welcome additions to the literature. As an extra plus, neither of them are remotely stuffy reads (which let’s face it makes a pleasant change from a lot of academic tomes!).

Reflections on a new article

Last week I was delighted to have an article published in the latest volume of Anthropology of East Europe Review. The material in this article was originally intended as a case study for my recent talk at this year’s BASEES conference, but it ended up being such a big issue that it really merited a more detailed treatment. Recently I replied to a tweet I spotted on twitter where a PhD student was lamenting that she had to relegate some data to a footnote in her thesis – the case on which this article is based was a ‘mere’ footnote in my thesis, and here it is published. So there is hope – the thesis is not the end product, but I’m certainly finding that 2 years on from graduating my thinking has developed and the things I am wanting to write now are very different from what is in the thesis itself.

The article is called “Constructions of childhood, victimhood and abortion in Romania: the ‘little-girl mother’”, and is based on articles I gathered during a 2 month period as part of my (much bigger) media review on sexual and reproductive health issues. This is the article abstract:

In June 2008 in Romania an 11-year-old girl found herself thrust into the media spotlight when it was discovered that she was 17 weeks pregnant after being raped by her uncle. Romanian abortion laws permit abortion only up to 14 weeks gestation. In the weeks that followed, the case was rarely out of the popular media, with debates about both the minutiae of this particular case and more general discussion about the appropriateness of the current legal provision taking place within the context of widespread concern about the phenomenon of fetiţe-mame (‘little girl-mothers’). This article considers the way the extensive media coverage of this case contributed to debates in Romania around abortion, childhood and child protection, but also exposed insecurities around national identity and Romania’s place within a wider Europe. It argues that this case serves as a “critical discourse moment” (Brown and Ferree 2005:10) which highlights concerns about legislative shortcomings around abortion, media and professional roles in child protection, and the construction of childhood more generally in Romania.

The full article is available here (open access). In one sense the choice of journal was a bit of a risk – Anthropology of East Europe Review is a journal produced by Indiana University, and submissions are generally editor-reviewed rather than peer-reviewed so from a career perspective it may not be the best thing in that it is not an article that could be submitted for the REF. However I like to think I was very strategic in my choice – due to my current contract I am not being submitted for the 2014 REF in any case, so the first REF (or whatever it will be that replaces it in 2020) that I need to worry about will be considering my publications from 2014 onwards. Obviously I also have to think about my publication record when applying for new jobs, so do need to also be targetting peer-reviewed outlets, but I did feel I could afford for this one article to think about where I would gain most exposure/impact for this particular piece, which as a case study may not have been considered by higher-impact journals. I also really like AEER’s philosophy of aiming for a fast turnaround of research, and of a commitment to disseminating research from regional and early-career scholars. I also very much admired the editor (although this is her final edition before handing over to a new editor) and many CEES scholars (both early career and senior) whose work I respect immensely have also published in AEER, so I am proud to be part of their number. I’m pleased my work can join their conversation. I’m also hopeful that as well as the area studies conversation, this article can contribute to the ongoing debates worldwide about abortion policy and legislation.

Professional use of social media

Recently there was a very interesting debate on GP and clinical lecturer Anne Marie Cunningham’s blog on the General Medical Council updated guidance on use of social media for doctors. There was quite a lot of concern expressed in the (very many) comments about the seeming requirement to avoid pseudonyms and use real names if identifying as a doctor on social media. The GMC clarified the guidance later, see here.

Following the debate made me return to the Nursing and Midwifery Council social media guidance to see what they had to say. As you will see from the link there isn’t anything in black and white (or even grey, particularly) about the use of pseudonyms, and the guidance is based on using facebook but says it is applicable to other sites too, including blogs and personal websites. This guidance seems relatively straightforward with a healthy dose of stating the obvious at first glance – don’t discuss work-related issues, don’t take and post pictures of patients online, don’t use social networks to pursue friendships with patients. The key it seems to me is to use common sense – don’t do anything in real life that would jeopardise your registration, and don’t do anything online either.

The pseudonym issue, which the NMC guidance doesn’t cover but the GMC guidance has elevated to veritable can-of-worms status, is interesting I think. I choose to use my own name on my blog and twitter (the two main places, along with a vaguely neglected academia.edu profile, that I use for largely professional purposes), and am open about the fact that I am a registered health visitor (although I’m currently working in research rather than clinical practice). Nothing I write here or on twitter should come as any great surprise to anyone who’s worked with me – I like to think that what you see here is pretty much what you get. I have chosen not to talk about things that I’m not happy to have my name associated with; and that’s pretty much it. I can see though that using a pseudonym might be helpful to some people – I’ve known people start off on twitter with a pseudonym because they were just nervous about identifying themselves in this unfamiliar environment and then that name becomes established. Some people feel they can be more open and honest in expressing their opinions using a pseudonym, and are concerned that if patients know that they are expressing opinions in social media that this may affect their relationship. I personally have no beef either way – I have made my choice, and obviously I think that other people should make theirs. This is why I must admit I did raise my eyebrows when I read the GMC guidance that doctors who identify as such online “should” use their real names – the clarification that “should” does not mean “must” still seems quite woolly to me in all honesty. I appreciate the reasoning, that if people are making claims in the name of medicine then identifying who they are will help in discerning whether those claims are credible or not. But it does still seem a bit heavy-handed to me.

I would encourage nurses and other professionals to think about professional tweeting and blogging. As a result of this – hardly prolific – blog, I have been able to be part of conversations recently about evidence-based practice and the future of nursing leadership amongst others, opportunities I’d never have had if I wasn’t involved in these sites. The usual provisos apply (see guidance above) – use your common sense, don’t be defamatory, don’t breach patient confidentiality, etc – but see this as an opportunity to be part of wider significant conversations. You never know who will pick it up – I found out after I started in my current post that my boss and colleagues had read my blog (presumably they had googled me when I was shortlisted) so knew that I could write a bit already. I’m not making any claims to literary or academic magnificence, but it’s certainly not done me any harm. I know that some people are nervous about the professional monitoring of social media use – in my last clinical job we were advised by a senior nursing manager that they receive around weekly requests from the NMC related to people’s social media use – but really, if you use your common sense and don’t do anything silly, I think that social media represents much more of an opportunity than a threat both to personal/professional development and to the chance to contribute to the debates that are shaping practice and services.

Nurse-bashing post-Francis

Just over a year ago I wrote a post called Nurse Bashing, in response to a news item which had wound me up, pointing out that nurses were something of an easy target to be singled out for criticism when something goes horrifically wrong in the health system as a whole. Ever since then I have been somewhat depressed (although not surprised) that “nurse bashing” is probably the most frequent search term which gets people finding my blog. And now, in the light of this week’s governmental response to the Francis Report into the failings at Mid-Staffordshire NHS Foundation Trust, the search term “nurse bashing” has been turning up ever more frequently. There has been a veritable storm at the inadequacy of the response, and perhaps unsurprisingly one of the main headlines attracting considerable debate is the recommendation that before training to be nurses, students should spend up to a year working as a health care assistant in order to better learn how to care. Lots of people have written very eloquently about this already (see for example this blog post by June Girvin from Oxford Brookes University, with which I wholeheartedly agree).

I’d like to offer some of my thoughts and questions about this (apologies this will probably be quite long!). In particular, I want to ask 1) why nursing is being targetted when Mid Staffs represents a systemic failure; 2) is a one year health care assistant post prior to nurse training a good thing for nursing; and 3) where next for nursing and nurse education?

1. Why is nursing such an easy target?
I can’t help thinking that the perception of nursing as an easy target is something of a reflection of nursing’s past status and image as ‘handmaids’ to the more powerful medical profession. This is perpetuated by (in my opinion) poor nursing leadership, with the Royal College of Nursing (RCN) and Nursing and Midwifery Council (NMC) seemingly completely separate from the Chief Nurses for the four nations of the UK. Could you name any prominent nursing leader? I’m not sure I could. What this means is that those of us further down the pecking order are easy targets. In addition, given that nursing is such a large workforce within the NHS, any action which impacts on nursing will not only have a big impact, but be seen to have a big impact – so it is relatively easy for the government to be seen to be “doing something”. However, this approach will not reflect the root, systemic causes of health service failure, particularly not when implemented in isolation.

2. The 1 year HCA proposal – is this good for nursing and caring?
Over the last couple of days there have been many arguments and debates for and against the proposal. In order to be transparent I should say that when I trained as a nurse (as a mature student) I had not had previous HCA experience (although I had done a bit of voluntary work with an AIDS charity), so I suppose I would say that a year as an HCA isn’t necessary for nurse training. I don’t have a particular problem with the idea per se – I can see that having had some HCA experience would probably have helped me a bit with confidence in my first couple of placements, and it may well be a good thing for some people to start to familiarise themselves with the ward environment and the realities of the job. I do though have a big problem with the idea as one of the primary policy responses to the failures of Mid Staffs, for all the reasons highlighted in June Girvin’s blog post.

I do have some other concerns about the proposal. Firstly, the proposal as espoused by Health Secretary Jeremy Hunt appears to be equating basic caring tasks (as carried out by HCAs) with caring as a quality, and I worry that this equation if not challenged will move nursing back towards being a primarily task-based occupation which will, in my opinion, have the opposite effect to the effect intended. Secondly, I think there are a number of logistical problems which I suspect may well not have been thought through fully, such as where does this leave existing health care assistants, and what will be the demarcation between permanent HCAs and pre-nurse training HCAs? What will be the impact on wards who invest time in training someone to be an HCA only for them to leave after a year? Will those people working as HCAs in the pre-training period be subject to the NMC Code of Conduct? (or, at least in Scotland and Wales, will they be subject to the HCA code of conduct?). In England, why has the Department of Health ruled out the registration of HCAs? (this is an issue which I think is much more urgent to address than what pre-training nursing students do).

In addition to these logistical issues, I will return to my usual bugbear when I am ranting about nursing and politicians: how will working on a ward as an HCA prepare students to work as nurses in the community? It’s not the first time I’ve complained about this, but it does just annoy me so much that politicians (of all stripes) seem to equate ‘nursing’ with ‘ward work’, when there are plenty of us who haven’t worked on a ward for years. I also have big concerns about the implications for university-based nurse education. Ever since Project 2000 first saw responsibility for nurse education shift from individual hospitals to universities, there have been vocal nay-sayers objecting that university-educated nurses have poorer practical skills, that essays and books are pointless and don’t prepare nurses for the practical realities of the job, and there seemed to be an implication that university-educated nurses were less caring as universities supposedly can’t teach caring as well as learning the job in situ. As a university-educated nurse I’m obviously going to disagree with this – I think a focus on being on the ward all the time (which is something I am starting to hear more and more from our esteemed political leaders) risks both dumbing-down of the nursing profession and maintaining nursing’s ‘handmaid’ status as students are less well-equipped to challenge poor practice and management (actually I suspect this is something that this current crop of political leaders would prefer). I’ve written before here about the attempted depoliticisation of the nursing profession as an aim and implication of a move away from university-based nurse education, and I think that this is something that should be vigorously resisted.

3. Where next for nursing?
I am not saying that there is no need for reform of nursing as a profession. I am though concerned that the target for policy change in response to major systemic problems in both the nursing profession and in NHS leadership and systems more widely are (as usual) the less powerful, lower-level frontline staff. This is why I think that nursing leadership is something that really needs to be looked at. The Francis Report did highlight shortcomings with the RCN, and I do think that as an organisation the RCN is ripe for a radical rethink as to its role and purpose. Unlike the medical Royal Colleges, the RCN is not solely an organisation for the promotion of and advocating for the profession of nursing. This is part of what it is tasked to do, but it also acts as a trade union for its members and provides considerable education resources. I think that a model more akin to the medical Royal Colleges would be preferable, and would strengthen the RCN’s leadership role in nursing and ability to influence the political debates. So I would like to see the RCN as solely a professional body, along the lines of the RCGP, freeing up RCN leaders to advocate for nursing and give it real ‘teeth’ to address weaknesses in the organisation of the profession. The union function should, I think, be either hived off into a separate organisation (for those who would prefer to be represented by a specialist nursing union), or incorporated into another of the existing trade unions active in representation in the NHS, such as Unite or Unison. In addition to the RCN, I think it is clear that the NMC has never really been fit for purpose (and I must admit whenever I send off my annual fee I always wonder what on earth it is being used for), with backlogs and internal staffing issues meaning that its vital regulatory function is being stifled and undermined. The fact that senior nurses leave the leadership of the NMC speaks volumes about the sorry state of UK nurse leadership, and I am not sure that with the current leadership of the nursing profession there will be any significant improvement in its shortcomings. I think leaders of the calibre of the RCGP’s Clare Gerada, who is regularly asked for opinions in the media and by politicians and who campaigned tirelessly to highlight the significant flaws in Andrew Lansley’s Health and Social Care Bill in England, are what is required as a first step in sorting out nursing. It is not leadership alone, of course, all of us nurses have the responsibility to challenge poor practice and management and promote higher quality patient care, but I do think that intelligent and inspirational leaders would be a good start. Certainly a focus on student nurses working as HCAs will do little to address the considerable shortcomings in nursing management and leadership, and it absolutely won’t address the systemic failures of the health service which resulted in Mid Staffs.

I do anticipate that there will be further attacks on university-based nurse education. Pat Thomson highlighted her concerns about Education Secretary Michael Gove’s bonkers, swivel-eyed response to academic critique of education policy here, and I wouldn’t be surprised in the least if there is an equally mad attack on nurse education before too long. Certainly the government has said more than once that nurse education should be moved back to the wards from the classroom (whilst not going so far – yet – as to advocate its complete removal from university). I am really concerned about this. I think that this represents a much more insidious attack on nursing and the profession’s ability to advocate for disadvantaged and vulnerable patients and challenge poor management and leadership than the frankly bizarre policy of insisting on a year of HCA work for students. I really hope I’m wrong.