Category Archives: nursing

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.

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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…”?

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.

Some thoughts on Triple P and evidence based practice

Over the last few weeks, thanks to the power of twitter (and particularly tweeter @LMarryat) I became aware of some journal articles and blog posts about the Triple P parenting support programme. I must confess to a possibly not entirely unbiased interest in this, as before my current academic position I worked as a health visitor in an authority which invested heavily in the Triple P programme and over a period of a few years we were all trained up and expected to deliver the programme at every possible opportunity.

Triple P is marketed as an evidence-based programme which provides support for parents of 0-18s who have issues with various aspects of behaviour. It is provided at several levels and the support can be provided to individual families or done as group work. As a practitioner, I was trained at level 3, which is the basic parenting support package for individual families. It meant that I was trained to give advice and support around all sorts of parenting issues – food refusal, tantrums, toilet training, home safety, whining, hitting, etc etc – through the structured programme, supported by tipsheets and a DVD (although I must confess to never using the DVD myself). For some families it seemed to be really helpful, for others less so – to be honest the materials seemed as good as anything else I’d seen, but not especially better, and there were some aspects of it that really jarred. Triple P is based in Australia so all the materials are developed there, and part of the deal is that the purchasing authority does not deviate from them, photocopy them or adapt them in any way. In particular I got a right bee in my bonnet about the Home Safety tipsheet – in an inner-city area of multiple deprivation, high rise flats etc it really got on my wick that I had to hand families a sheet which told them how they must make sure that their children don’t go near the swimming pool in the garden unattended. That’s the most extreme example, but I just think it typifies the issues that many of us had with the actual materials. The other thing that made me cross was how we weren’t allowed to get the sheets translated for our families who spoke minimal or no English – there were some sheets in a few languages, but not enough for everyone who needed to use them across the city, and not in all the languages we came across in our practice, in a city which was one of the major reception cities for dispersed asylum seekers. This meant that it was really hard to offer the same level of support to families who were just as much in need of help as the English-speaking population. We also did have other issues which in a way were not Triple P’s fault and were more to do with the way management basically forced us to deliver the programme whether we wanted to or not – it became an exercise in numbers, in filling in forms and ticking boxes, and is one of the main reasons why I finally decided it was time to leave. It was getting to the point where I felt that I had no choice but to offer families a Triple P intervention, regardless of whether I thought it was what they needed, because of the pressure (and there really was pressure) to meet targets and figures. What also irritated was that Triple P was rolled out across the city at the same time as all the staff had to endure a 2 year pay freeze, and when we complained about the pressure to deliver Triple P we were basically told that as they had spent so much money bringing it in, tough we had to do it anyway. So when I say that I’m not entirely unbiased, perhaps it would be more accurate to say that I’m really quite bitter about it! (grrrr!)

One of the things that we were often told, again and again, was that Triple P was so great because it was “evidence-based”. I didn’t have access to university libraries at the time so it wasn’t easy to access articles, only abstracts, but I did a Google Scholar search and noticed that pretty much every article about Triple P featured the name of Dr Matt Sanders, who is the person from the University of Queensland who developed Triple P and is very involved in the materials, promotion and training development for the programme. I wasn’t able to get hold of the full articles due to paywalls, but this discovery did leave me with some questions about the evidence and the risk of conflicts of interest.

More recently, studies have started to emerge which call the evidence base for Triple P into question. Mostly they seem to be highlighting that the claims of the evidence to date can be questioned due to small sample sizes of the various research. There is also a recent trial with larger numbers that did not involve the Triple P team which compared Triple P level 4 with two other parenting programmes in Birmingham (Little et al 2012) where there were no discernible effects from Triple P. Following this, a systematic review and meta-analysis article by Scottish researchers in BMC Medicine (Wilson et al 2012) raised questions about the current evidence base (as outlined above – small sample sizes, potential conflicts of interest), which was also blogged about at PLOSOne by Dr James Coyne here. There then followed a response from Dr Matt Sanders et al here, and Dr James Coyne & Dr Linda Kwakkenbos also responded to both article and response here. [And as an aside, hooray for open access!] There is also a blog post which summarises the discussion and issues by Dr Pedro De Bruyckere here, which also provides a link (unfortunately in Dutch, not one of my languages sadly) to a recently defended PhD which found no significant effect of Triple P interventions. I must say from my experience as a practitioner I absolutely agree with his concern about a lot of money being involved which I do think affected how we as professionals were expected to push the programme.

What is worrying about that final blog post is the discussion about the difficulty in publishing null or negative results of research. This seems like the ideal point to publicise the Alltrials campaign, which is highlighting how much publicly-funded clinical research is not reported at all, meaning that trial results are lost to future researchers. Please do sign the petition if you have not already done so! There are all sorts of reasons why research might be buried, but regardless I agree that it is vital that all clinical trial results are published so that their findings are available not only to inform future research but also to inform current clinical practice. There can be no excuse, particularly in these straitened times, for publically funded research to be buried. What has shocked me though – I guess I must be naive, it hadn’t actually occurred to me before that this could happen – was the issue of publishers declining null/negative research results. That is a really worrying development that must be resisted.

[Edited to add]

One thing which saddened me as a practitioner was that, in discussing with my health visiting colleagues it seemed that there was another parenting programme (whose name escapes me at the moment) that they had been trained in and using before the drive to use Triple P. All of them were unanimous about how much they liked it, how much they thought it was making a difference, but that when the decision was made to plump for a programme which would be rolled out across the city it lost out as it did not have the requisite “evidence-base”. I just think that is such a lost opportunity – I appreciate that in a city where parenting and anti-social behaviour is often an issue at a large level that a community approach needs to be taken, but why could they have not done some good quality research, perhaps even comparing this programme with Triple P, to start to build an evidence base? I wish they had been brave enough to do that – they might well have kept the goodwill of their staff (which was sorely lacking with the way Triple P was introduced) and seen some great results. I can think of one researcher (not a million miles away) who would have loved to have been involved with the qualitative aspect of that sort of study.

Book Review: “Using Research in Practice”

Some time ago I was fortunate enough to benefit from the largesse of the British Journal of Nursing in a twitter giveaway (you can follow the BJN on twitter @BJNursing). The book I received was “Using Research in Practice: It Sounds Good, But Will It Work?” by Jaqui Hewitt-Taylor. I loved the premise of the book – it is aimed not at researchers per se, but at practitioners who need to appraise research in order to think about its relevance and application to their clinical practice. This is, I think, a very useful aim: I remember as a student nurse doing my research module, and struggling to find sources which explained in simple language what research was actually all about. Later, after I qualified, I picked up a bit more about appraising the suitability (or otherwise) of research claims, particularly thanks to a group of district nurses I worked with who (I later discovered, from a friend who managed medical reps) had a bit of a reputation for grilling medical reps and giving them a hard time when they visited and plied us with sandwiches and free samples and tried to get us to buy their wound dressings. However, I must admit before starting my PhD to being really quite vague about the ‘nuts and bolts’ of clinical research, and it is here that I think this book has much to offer.

The book is in three sections, “What is research, and why should it be used?” which outlines the benefits of research and the basic definitions, paradigms, ethical issues and methods/methodologies, followed by part 2, “Is the research any good?” This largest section discusses finding and appraising research generally, before more specific chapters on different types of research (quantitative, qualitative, mixed methods, and summaries of evidence). The final section looks at “Putting research into practice”, including making decisions about incorporating research findings into practice, and the practicalities of managing change.

The substantive chapters on appraising research were all easy to read, and set out in a way which I found very helpful for the non-researching practitioner. Each chapter starts with a brief scenario, which outlines a practice-based dilemma requiring some appraisal of research evidence. The bulk of the chapter then outlines the principles of the particular type of research under discussion, and includes consideration of methods, methodology, sampling and analysis. Crucially this includes discussion of the relevance of the particular type of research to the research question in the scenario, and this is in my view a particular strength of the book, which I think is accessible and easy to follow. The chapters end with worked examples, with another scenario and discussions of two papers which may or may not be relevant and appropriate to the requirements of the practice dilemma. As a student and relatively newly-qualified nurse I am certain that I would have really appreciated a source like this to help me make sense of all the clinical research that we were expected to understand and assimilate with minimal research training.

My area of interest/expertise is in qualitative research, so that is the section I turned to first, and I was pleased to find no howlers but material with which I was in general agreement, which boosted my confidence in the credibility and authority of the author. After this I turned to the chapter on quantitative research (where I am on much shakier ground!) and there I found simple and easy to understand explanations which I greatly appreciated (although I do wonder if I found them thus because I have read more research over the years and have a greater understanding of general principles of research so was not approaching it from a zero-knowledge base). I am sure though that as a qualitative researcher currently working in an area where there is a lot of quantitative research of which I need at least a basic working grasp, I will be returning to this chapter more than once!

There were a few minor irritants about the book; a few spelling/punctuation errors which should have been spotted by the editor, particularly in the opening chapter, and most annoying for me, a number of passages where the author explains her point using chatty anecdotes about things such as a holiday in South America, niggles the editor might have with the author, and something to do with ice cream (if any of my OU students read this they will no doubt recognise this criticism; I do not expect an informal chatty style from students so I certainly don’t want to see it in published academic authors! Although I do realise this probably says more about me than about the author!). The substantive chapters, where points were explained using clinical examples and scenarios, were so well done, relevant and easy to follow that the excessively chatty and anecdotal style in those more personal examples seemed out of place and unnecessary.

I did feel that the latter chapters, whilst of interest to student practitioners, would be of most use to those already qualified and in post, in more of a position to effect change in the practice setting. However the book as a whole is to be welcomed as a useful addition not only for practitioners but also students to help ‘demystify’ research and hopefully encourage them that research is a vital part of practice rather than yet another additional burden.

Qualified to advise?

Looking at Twitter yesterday between marking essays, I happened to look over at the UK ‘Trending Topics’ (something to which I usually pay little attention) to find that ‘Gina Ford’ was trending. Gina Ford, for those who don’t know, is the author of a number of parenting books, the most famous of which is ‘The Contented Little Baby’. Her methods are controversial and contested, and with my health visitor hat on I have to say that I am absolutely and resolutely not a fan. There are a couple of newspaper articles here and here which discuss her methods, and I think this post on the Every Child Matters blog sums up very neatly my own concerns and more besides about her particular proposed methods of establishing an early routine with young babies and children. Gina Ford herself rebuts some of the criticisms of her methods here. She was trending on Twitter yesterday as she had been on a morning TV show promoting her latest book (called ‘The Contented Mother’s Guide’), and also was the subject of an article (apologies, it’s a Daily Mail link) in which she is reported to be suggesting that women have sex with their partner within 4-6 weeks of giving birth, regardless of whether or not they feel ready for it. [Update 8.3.12: see end of post]

What I want to discuss here though isn’t Gina Ford and her particular methods and views, as these articles show there are plenty of other places on the internet discussing these at great length. What struck me yesterday when I was looking at the comments on Twitter about this, and also the comments on the articles I linked to, was the large number who are focusing on the fact that Gina Ford does not herself have children, and using this as a reason to dismiss her views. I need to give a disclaimer here: I am a qualified health visitor so have been in regular contact with her target audience, and I do not have children. So I am aware that this is pushing some personal buttons. However, that aside, there is something I think quite troubling about comments such as ‘bah, it makes me sick that someone who hasn’t even had children can spout all this nonsense!’ (the first comment on the Every Child Matters blog post linked to above) or ‘”The divorcee, who has never had children..” says it all. Not been there, have no right to offer advice.’ (one of the comments on the Daily Mail article). I tweeted in response the following:

“shouldn’t have clicked on Gina Ford trending topic. Grrrr – Daily Mail *and* GF (but also troubled by ‘if not had baby don’t advise’ trope).”

and one person (@Superleelee80) tweeted back:

“why troubled? I could research climbing mountains and spout advice but why would anyone listen when I’ve never climbed one?”

It is of course a good question, an obvious one even, and to be honest I was surprised she was the only one who questioned my discomfort. My two part reply was this:

“Worked with some great HVs who’ve never had kids (some who can’t), and terrible ones who have. Person more imp than life exp.”

“my probs with GF about rubbish she says/claims and damage it does, rather than if she does/doesn’t have kids.”

On one level I think this is about the old mantra “attack the issue not the person”. There is enough to criticise in what Gina Ford is saying without having to resort to personal attack (as well as criticising her lack of children, there were a lot of comments making very personal remarks about Gina Ford’s appearance), and I think that by focusing on personal details the argument against the aspects of her methods people are troubled by is weakened.

I also though think (and this bit still requires some thinking on my part, but I will throw the hunch ‘out there’ so I have something to come back to later and flesh out) that there is something here about the elevation of mother/parenthood which is particularly illustrated by the ‘Not been there, have no right to offer advice’ comment. I remember when I was first qualified as a health visitor, I was chatting with a friend online when she asked me pretty much the same thing – how could I possibly help a struggling breastfeeding mother when I have never breastfed myself? To which I was happy to give the example of the client who had told me that if it hadn’t been for me taking the time to watch her feed and help her with positioning and attachment then she would have given up. I have come across similar arguments about male health visitors (and male midwives, an even rarer breed), yet one of the best health visitors I ever worked with was a guy, and my mentor when I was training (still the best health visitor I have ever worked with) was childless. I have worked with great people, several of whom would have loved to have children but sadly it didn’t/couldn’t happen for them, and I have also worked with people who were parents but who in my opinion had terrible skills when it came to relating to the people they were meant to be helping. I maintain that it is not motherhood which primarily qualifies someone to give parenting advice – of course it might help, but it is not inevitable (if an advisor themselves had a perfect parenting experience they may not necessarily be able to advise or relate to someone who is struggling, after all), and I cannot be more categoric that mothers/parents do not have the monopoly on empathy. The talk about ‘right to advise’ particularly troubled me, not just on the personal level, but also that elevation of motherhood reminded me of (small c) conservative debates around family being the basal cell of society (a trope which appeared often in my PhD media review of coverage of issues relating to sexuality and reproduction). Families come in all shapes and sizes and makeups, with or without children or partners – elevating one type above others is dangerous and exclusionary and does nothing to promote healthy, happy children and well supported parents.

Update, 8th March 2012: this morning via Twitter a representative from Gina Ford’s publishers sent me this announcement, refuting the reported claim that she was suggesting parents should have sex within a few weeks of birth. I would like to make it absolutely clear that nowhere in this post did I make any comment on this particular claim (much as I was tempted to), other than that it was reported and had therefore made Gina Ford trend on Twitter, and the substance of this post was my concern about the oft-repeated claim that as Gina Ford does not have children she is not qualified to advise about parenting.

Nurse bashing

Over the last couple of days there has been considerable coverage of David Cameron’s “brave attack” on the sacred cow of nursing (outlined by the Guardian here). “Brave” because, as Dave tells us, despite the fact that the “vast majority” of nurses are doing a marvellous job, successive governments have “lack[ed] the bravery to tackle the issue” (“the issue”, apparently, being “the “real problem” with nursing in the UK”). Er, run that by me again? ….. Apparently the solution to this is hourly ward rounds and patients inspecting hospitals, and a reduction in paperwork (and though I am no fan of excessive bureaucracy I am yet to hear about how we are supposed to evidence the work we do, to managers, funders or indeed courts, or hand on work to other staff, without the paperwork).

I’m not going to go on about one of my particular bugbears about Cameron’s pronouncements about nursing, the fact that he always seems to equate nursing with hospitals/wards (see my previous post after the November 30th strike for more on that) which drives me up the wall. Nor am I going to go on about how all nurses are wonderful, of course some are better than others as in any profession. There have been some horrific cases highlighted in the media of individual nurses working way outside the bounds of our Code of Conduct, up to and including the unlawful killing of patients. As there have been with doctors (Shipman, anyone?), and hospital wide failings have also been widely reported (the example of Mid Staffordshire Hospital being the most obvious recent example; hospitals this side of the border have also not been immune). It does worry, not to mention really annoy me, though, that nurses as a profession are singled out like this as responsible for care failings when health care is not only multi-disciplinary but also subject to the political whims of the day. I will be interested to see what the leaders in the profession (chief nurses, RCN, union leaders and others) have to say about this and how vigorously they will defend us. I can’t for a minute imagine the BMA staying silent if this type of attack was made on doctors as a profession.

I am also concerned at the ‘one size fits all’ tone of Cameron’s so-called solution. What has clearly worked well in Salford (from where Cameron proposed the hourly ward round; I wonder if he had thought of that before or if he just heard about it there and decided on the spot that it was the answer) may or may not work elsewhere. Staffing levels, profile of patients, number of patients per nurse, availability of appropriate equipment, support from management*, etc, all differ, so the implications for the working day of staff undertaking a daily ward round are very different from one workplace to the next. Individuals and communities vary, and ‘one size fits all’ does not and cannot apply, particularly in health care where the experience of both patient and nurse varies so much from day to day.

In qualitative research we are careful to say that our work is largely not generalisable (although the more research is done, the wider the net can be cast in terms of identifying similarities) beyond the group/population studied. Some would suggest this is a weakness, but I would argue that it could be a strength, in that it enables policy informed by research to be truly responsive at a more local level rather than reactionary. With my researcher hat on, I would like to see research done at local level to identify what are the specific issues which arise in that particular health care setting, and (crucially) involving the staff as well as patients/clients in identifying what can be done practically to build on good work and address limitations/poor practices. I realise that this is idealistic and funding for such research and consultation is limited; however I am not at all convinced that a ‘one size fits all’ approach as advocated here by Cameron is an appropriate or sustainable alternative.

* don’t get me started!!! I do apologise for the rant, I will try very hard not to rant next time! 🙂