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Wednesday 11 April 2012
Reforms in the 1990s were supposed to make nursing care better. Instead, there's a widely shared sense that this was how today's compassion deficit began. How did we come to this?
The second part of our week-long series on the crisis of caring in British nursing addresses the question of what, precisely, has gone wrong
Yesterday, Christina Patterson described how extensive first-hand experience of Britain's hospitals persuaded her that all was not well with British nursing – and how subsequent research suggested that her disquiet was widely shared. Here, she tries to identify the origins of the crisis.
When I asked people who worked, or had worked, in the NHS what they thought had caused the biggest changes in nursing care, nearly all of them mentioned something called Project 2000. This was a new system introduced in the early 1990s, which moved the training of nurses out of hospitals and into universities. Instead of the old apprenticeship system where nurses were attached to hospital schools, and trained on the job, they now had to study off-site for a diploma, or degree. And now, even the diplomas are being phased out. By next year, all nurses who qualify in this country will have to get a degree.
Project 2000 was designed to reflect the fact that medical treatments, and clinical care, are getting more sophisticated every day. Nurses, said its champions, needed to have a full intellectual grasp of the increasingly complex treatments they were involved in delivering. The best place, they said, to get this was in the classroom of a university. And if putting trainee nurses in universities challenged traditional views of hierarchies, and the subservience that went with them, well, that wouldn't do any harm.
"Nursing," says Anne Marie Rafferty, Professor of Nursing Policy at the Florence Nightingale School of Nursing and Midwifery, "is one of the toughest academic disciplines. The curriculum is very highly regulated, and very demanding. The concentration of graduates coming up into the profession is going up. The more talent we can attract, the better that will be for the profession."
But quite a few people disagree. Chloe Nightingale, who not only shares the name of the world's most famous nurse but also trained at the Nightingale school in the 1970s, contacted me after hearing the Radio 4 broadcast of a talk I gave just over a year ago about my experiences of nursing. She had, she said, found her own treatment as a patient, and that of friends and relatives in hospital, "generally appalling". It had, she said, left her "in tears of frustration".
When we met, with Anne Marie Rafferty, for a coffee just down the road from where she trained, she said she could see that "there were a lot of benefits to doing a degree", but that she also had doubts. "If you look at medicine," she said, "and the most intelligent people who go into medicine, that doesn't necessarily mean that they're going to be the best hands-on doctors. They have the brain, but they don't always have the empathy. That's what concerns me, that the empathy has gone."
Chloe Nightingale has one daughter who's studying to be a doctor and another studying to be a nurse. She thinks one of the big problems is that nurses are now "trying to be mini doctors". "The next thing," she said, "will be that in order to be a ward sister you'll have to have a Master's degree. Why? Nursing is not rocket science. In certain areas, yes, you do need to have a brain, and you do need to be able to think on your feet, but I really don't understand why they have to make something that's a basic instinct in some people, that's the delivery of care, into a highfalutin job that's going to rule out people who'd be bloody good nurses."
It is a view that a fair number of doctors take, too. Paul Goddard, a retired NHS consultant radiologist says, in his book The History of Medicine, Money and Politics, that he has "personally overheard nurses moaning that they are fully trained medical scientists and should not be expected to deal with patient needs such as bedpans". From "day one", he told me, "nursing lecturers tell the student nurses that they are not the handmaidens of the patients or doctors, but that they are equal professionals". And then, he said, "when they find themselves on the wards, they're surprised to discover that nobody cares about their scientific pretensions". This, he said, "is a bitter pill to swallow".
Patrick Strube, a consultant in intensive care in the NHS, doesn't go quite as far as that, but he does think it's a problem that student nurses are "trained in the classroom by nurse 'educators' who haven't done any actual nursing for years". There is, he says, a "reluctance to help medical staff". Nurses "are not prepared for the consultant round" and "lack knowledge of the patients and events".
You'd expect doctors to be unenthusiastic about a system that has made nurses less deferential, but some nurses also think it's gone too far. It almost looks, I said to one very senior nurse at a leading London teaching hospital, as if a whole profession has been radically shaken up just to get rid of chips on shoulders. "I agree with you," she said. "I don't think you have to downplay the caring side of things just to make yourself more equal. I worry that we've tried to solve everything with a piece of paper."
It wouldn't be fair to say that Project 2000 has produced nurses who are "too posh to wash", or that their training is all about theory, and not practice. Trainee nurses do spend about half their training time on the wards, but they are supervised by "mentors" who are often too busy doing paperwork to help them turn theory into practice.
Chloe Nightingale's daughter, Penny Edwardes, who is currently doing her nurse training at the Nightingale School at King's College, told me the nurses on one of her placements were known for "not being brilliant" mentors. "It sort of felt," she said, "like a bit of a waste of space. They wanted to get on with their jobs, and didn't want to have to do the mentoring. When you're first starting, it's largely observations and paperwork, and just standing around."
"Students," said Anthony Ingleton, a recently retired lecturer in nursing, "are now taught less nursing, and less about the elements of fundamental care. So as universities push out cohorts of practitioners who are, in some respects, less prepared, the expertise in practice is diluted."
When Project 2000 was introduced, the system of State Enrolled Nurses, to support the State Registered Nurses, was also abolished. The SENs, who had two years training, were replaced by healthcare assistants who aren't registered, or even formally trained. Even after my six stays in hospital, and after talking to scores of people who work in the NHS, I'm not at all sure how this system is supposed to work. I certainly didn't realise that some of the people who were meant to be looking after me may have had no training at all. It wasn't clear who, if anyone, was supposed to make sure that patients were fed, or washed. And if it wasn't clear to me, it probably wasn't all that clear to anyone else.
"The public," said the report Frontline Care, which drew on consultations with 300 organisations and thousands of patients, "is confused about what a nurse is." Even nurses, according to the report, are confused. No wonder patients often aren't clear who, on the ward, is meant to be doing what.
Patients also aren't clear who's in charge. When I discovered that the nurse who was meant to be looking after me, after an eight-hour operation with a high risk of complications, didn't even know what operation I'd had, I asked to speak to the person in charge. The nurse I spoke to, who wasn't the one who'd been assigned to my care, didn't know who this was. She disappeared for quite a while, and then told me that, since it was a weekend, there was "no one" in charge. If nurses don't even know who's meant to be supervising their work, and who will hold them to account if it isn't up to scratch, it isn't all that surprising that it isn't always great.
There is, of course, no point in hankering after a system where a dragon of a sister barked at her charges for a speck of dust on a bed pan, or a ladder in a stocking. The world has changed, and so has the work nurses do. Nurses now hover over computers because a lot of their work, like almost everyone's work, means they have to hover over computers. Nursing care involves large amounts of paperwork, and endless lists. This isn't just "red tape" that can be dropped. More complex medical care means an awful lot of things have to be checked and recorded, but it also means nurses tend to focus on the task, rather than the patient. Nurses have targets, and they have to meet those targets.
But if you're the patient, as Alan Baddeley, Professor of Psychology at York, pointed out to me, it can feel as if a management consultant has "tried to make a list of all the components needed for care" and "assigned them to the minimal level of competence that might be able to achieve that task". It might, he said, "work well in car manufacturing" but it doesn't "seem to work on a ward".
The shifts, too, have changed. There used to be three shifts a day, with an overlap at lunchtime, which ward sisters encouraged nurses to use to chat to the patients. Now, and presumably in order to save money, there are usually just two. This means that many nurses work three 12-hour shifts a week. It also means that by the end of those shifts they're pretty tired. "To expect people, particularly in something like coronary care where you've got to be on the ball all the time, to have that level of concentration, and to be the same throughout the day, is," says Chloe Nightingale, "just ridiculous. No wonder mistakes get made."
But 12-hour shifts, though tiring, are popular. "If you were to offer most public sector people three 12-hour shifts a week," said one Independent reader who has worked widely in the public sector, "they would snap your hands off, and immediately look for a second job. The NHS/public sector job would become one to get through with as little hassle as possible, so you could be fresh and fit for the second job (agency nursing in a private hospital?) which might be the one where better attitudes are actually demanded."
Most people I've spoken to seem to think that management structures in hospitals are now so complicated that no one really knows how they work. One nurse told me that there was a "complex matrix of overlapping authority", where directors of nursing, associate directors, heads of service, operation managers, transformation teams, clinical facilitators and matrons all jostled for power. At the peak of this matrix is the chief executive of the NHS trust, but the chief executive isn't the person nurses report to, and rarely makes regular visits to the wards.
What all of this seems to have led to is mass confusion and stress. Nurses feel accountable to managers they think don't understand their job. They feel weighed down by paperwork. They think doctors don't respect them, and patients don't appreciate them, and managers are constantly dreaming up new "initiatives" that they expect nurses to "cascade" down. Perhaps it's not surprising that many have, as Patrick Strube explained to me, become "institutionalised and demoralised". They feel, he says, that "their work place is unsatisfactory and maybe dangerous, but they feel unable to get their voice heard". So, he says, "they keep their heads down and hope not to get disciplined".
Perhaps it's also not surprising that sickness levels for nurses are much higher than the national average. Or that nurses who see bad care around them prefer not to speak out. One who contacted me said "the real conditions in which we work and the way people are treated are woefully underreported". She would, she said, "so love" to hear that she could report her experience without feeling that her "management would find out". Another said that she and her colleagues were "worn down by being the Government's puppets".
"Our pay is better than it used to be," she said, "but we have a lot more responsibility than 15 years ago. We deal with life and death still, but a very difficult, litigious and often aggressive public, and very frightening and stressful situations, and knowing our great accountability makes us very stressed at work. It is a technical and production line role now." She hoped to leave her job soon. "I am burnt out," she said, "and I fear I have lost compassion".
Nurses are struggling. Some are doing an excellent job in very difficult circumstances. Some are doing badly in systems that don't seem to give them the support, or training, they need to do their jobs well. But one thing is clear. Their leaders, and their managers, are letting them down.
Tomorrow - part 3: Culture and compassion – is the crisis in nursing a symptom of a wider malaise?
Special report: A crisis in nursing
* Day One: Six operations, six stays in hospital – and six first-hand experiences of the care that doesn't care enough
* Christina Patterson: More nurses, better paid than ever – so why are standards going down?
* Leading article: What can and should be done about nursing
* Day Two: Reforms in the 1990s were supposed to make nursing care better. Instead, there's a widely shared sense that this was how today's compassion deficit began. How did we come to this?
* Day Three: How can a profession whose raison d'être is caring attract so much criticism for its perceived callousness? Does nursing need to be managed differently? Or is the answer to develop a new culture of compassion?
* Day Four: The nurses who taught an ailing hospital how to care
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