Who'd be a nurse?

Nursing is in crisis over pay, morale and training. What makes nurses join and why do they stay?

Carol Seabrooke started her first job three months ago and says that she's dog tired, but still loves it. "It was always what I wanted to do. It was always there in my mind."

Sylvia Denton also has kept faith with the job she began more than 30 years ago. "It's challenging, it's rewarding and I wouldn't do anything else for the world."

Whether their feelings are shared by their co-workers is in doubt. For Carol and Sylvia are nurses - Carol works in the cardio-thoracic unit at St George's Hospital in Tooting and Sylvia as a breast-care nurse at Barts - and the past two weeks has seen a crisis in nursing as two separate studies revealed that the profession is more unpopular than it has ever been.

"Nurses are still being treated like children by the NHS." said a spokeswoman for the Community Practitioners and Health Visitors' Association in response to the report. "They will tell you it is not that it is unattractive but that it is unbearable to be a nurse."

Something must have gone badly wrong with this most caring of professions for the United Kingdom Central Council of Nursing, Midwifery and Health Visiting to announce this week that the number of those entering nursing had fallen to its lowest level since records began. One in four new registrations now come from nurses recruited from overseas and, for the first time, more than half the nurses on the register are aged more than 40. A quarter will therefore be eligible for retirement by the year 2000.

Add to that figures released in the past fortnight showing that one in 10 health-care staff have been assaulted, and that male nurses are twice as likely as women to be serving in the highest nursing grades, and it seems fair to ask why should anyone want to become a nurse at all?

Carol and Sylvia are currently at different ends of the nursing spectrum. As a newly-qualified nurse in the ITU, Carol's day starts at 7.30am when she goes on shift, relieving the night nurse. She checks the beds and then starts ensuring that all the drugs for the patients are given out. "It was scary suddenly finding yourself on a ward for the first time, knowing these people were dependent on you." As one of the youngest on the ward, her job consists mainly of observation. "It's far more pressurised than on a normal ward because the patients can often do little for themselves so you have to be watching them constantly and making sure they are all right. I also do a lot of work talking to the relatives, letting them know what goes on."

But working in a hospital can be extremely stressful. "The most frightening thing was when a patient collapsed and started kicking out, lashing out at all of us. There seemed to be no reason why and we couldn't get near him to stop him."

Sylvia, who after 30 years in nursing, is now a clinical nurse specialist, the highest grade a nurse can reach. She leads a team of three nurses in the breast-care unit and her day is divided between teaching, research and clinical work. "I'm lucky because I don't have to deal with the bureaucracy side of things. And I'm also lucky because a fair amount of my time is still taken up with clinical care. I still work down on the wards and see the patients. It's all about going there and being with the patients. They are so brave at what is a terribly worrying time."

Carol works a shorter week than Sylvia did when she qualified in 1963. She now works 37.5 hours compared to the 44 hours young nurses were expected to do in the Sixties. But nurses today say there are more patients who are sicker and they are constantly trying to overcome more work pressures.

But the current discontentment among nurses is due mainly to the poor pay. A staff-nurse's starting salary is pounds 12,633. At the other end of the scale, the most senior nurses like Sylvia, with responsibilities ranging across a whole trust, can be up to pounds 26,000. The Royal College of Nursing pointed to a recent edition of the Belfast Evening Telegraph where an advert for a nurse had a lower salary than that of a dog warden.

"No one ever goes into nursing to get rich," Sylvia says. "I think the feeling is that nurses want to be valued. They want people to recognise the work they do."

"When I was in training, people kept on at me about how bad the pay was, but it didn't put me off," Carol says. "But now I've qualified, I've realised how difficult it is - paying the rent, food and everything. It's so expensive living in London."

Pay is not the only issue. There have been radical changes in the nursing profession over the past decade, as one school seeks to make nursing more academic, and is virulently opposed by the other side.

"I'm not at all surprised by the recruitment crisis," a spokeswoman for the CPHVA says. "This move towards academic education means that good people have been excluded. You get nurses with diplomas who may have written 10,000-word dissertations on the sociology of health care but can't make a bed."

Over the past 10 years, Project 2000 has been phased in, which places more emphasis on theory. Carol trained this way at South Bank University. "In the first year I was mainly studying in college, doing things like anatomy and physiology and doing a few days on the ward. We did more work on the wards as the three years went on."

It's a far cry from Sylvia's experience - three months' training "learning basic anatomy and how to make beds", and then straight on to the wards. "It wasn't quite `Hello Nurse Denton, the sluice is over there'," she says, "but nearly. It was far more regimented. You knew your place and worked your way up gradually. We had longer working weeks then, and had to do night shifts for three months at a time. When I started there wasn't the same structure. You had to be driven to get up the ladder, otherwise it was very much work your time. When I went into breast-care nursing after being a health visitor there were fewer of us - hardly any at all."

"What we've got to remember when we look back to the good old days is that there was a lot of exploiting of young women," says Christine Hancock, general secretary of the Royal College of Nursing. "When I was training, only a third of nurses completed the course as there was a kind of First World War philosophy - throwing more and more young and inexperienced people into the trenches when others didn't survive. While it was seen as a thing for nice young girls to do while waiting to get married, young women were put on wards without support or full training. The other thing is that nursing is the only profession in the health service now where you don't have to have a degree: therapists, physiotherapists, even the ward hairdresser is likely to be a graduate. We want nurses to be on the same level. I don't believe this British idea that if you're intelligent you can't be good with your hands. There's no evidence for that."

Making life safer for nurses also is a problem that has to be addressed. Both Carol and Sylvia admit it can be "scary" starting off working on the wards. Sylvia says she was assaulted many years ago and Carol says that she has witnessed assaults. But as Sylvia points out, the NHS cannot turn people away: "It is an issue for the NHS and one we have to address, but we have to remember that we are trying to provide healthcare for all and have to accept that people have problems but we still might be able to help them. We do need to ensure the safety of nurses but we have to help people too." So would you recommend that anyone goes into nursing? Carol and Sylvia are determined they would. "Yes, don't go into nursing if you want to be a millionaire," Carol says. "But I've always wanted to care for other people and I really feel I'm making a difference."

"We need to sort out issues like pay," Christine says. "But despite all the problems most people say they wouldn't swap their job for the world. You get respect from the job and you know that you're doing something you believe in. Oh, and you'll never be bored."

"Working in breast care is rewarding," Sylvia says. "You're there with them right from diagnosis, helping both the patient and the relative, explaining to them what is going on. And you see such terrific courage from these women in what is a terrible time for them. I find it so humbling. The best thing is when I see them walk out of that ward and go back home. It is just brilliant."

Additional research by Peter Mann