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.