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 three: It is widely agreed that something has gone wrong with nursing. But are our nurses at fault? Or is Britain suffering from a wider malaise?

Christina Patterson
Friday 13 April 2012 00:17 BST
Florence Nightingale laid the foundations for modern nursing a century and a half ago with her work in the Crimea
Florence Nightingale laid the foundations for modern nursing a century and a half ago with her work in the Crimea (Getty Images)

Most nurses want to care. Some who contacted me after Radio 4 broadcast my talk about my experiences as a patient could hardly contain the anger they felt when they heard how some of their colleagues were letting them down. "I cannot reconcile it with what I know about my own practice, and that of my colleagues," said one staff nurse with over 30 years experience. "I also," he said, "have the privilege of teaching student nurses, and they sometimes shame me by their lively idealism."

Another, who worked on a breast care ward, said that he often worked "with tears held back" for the "spirit and the bravery" of the patients he nursed. The management at his trust, he said, was cutting back on staff, but he tried to make sure his patients didn't suffer. The trust, he said, didn't provide food for snacks in the evening, so he and a colleague left for work early in order to "pop into the supermarket" to buy biscuits for the ward. They were, he said, in case I was worried about the money he was spending, only "own brand".

Every one of the nurses I stopped and questioned, at the end of long shifts at two of London's biggest teaching hospitals, said they were "proud" to be a nurse. It's possible that the ones who wouldn't talk to me, and who just wanted, fairly understandably after a 12-hour shift, to get home and collapse, were the ones who weren't. But all of them said they were upset by reports in the press of bad patient care. "If I serve my patients," said one, who trained in the Philippines, "I think they're happy. I don't rush home. I've been a nurse for 25 years, and I never go rushing home."

"I try to give my best at all times," said another. "If there was a shadow of doubt in my mind that I could give good care, I wouldn't do it," said another. "I always put empathy in it," said another. "I try to think about how would I like to be treated? You have," she said, "to treat each person as an individual."

All the nurses I stopped said they thought they gave their patients good care, but they also said that this was difficult when they were short-staffed. "I'd say that the majority of nurses are caring people," said one. "I've worked from eight till now," she said, "and I was coming out smiling."

I have no doubt that each of these nurses was dedicated to their work, and I wish they'd looked after me. But it seems clear that one very big factor in compassionate care is culture. Different cultures have different approaches to care. Many of these nurses were Filipino and Caribbean. Filipino and Caribbean nurses are often trained in an environment that puts a big emphasis on the compassionate side of care. Some nurses working here – and about a third of the nurses in London are from overseas – train in countries where hospitals expect the non-medical aspects of care to be largely undertaken by patients' families.

But the much bigger issue is with British culture, and with the culture of individual hospital trusts and wards. British culture has changed. We value care much less than we used to. Many of us, as the MP Margot James pointed out in the debate she tabled in October on care of the elderly, seem to be more interested in our rights than our responsibilities. Nursing takes a bigger proportion of young people out of schools than any other profession, and these people, however well-intentioned, are going to reflect the attitudes of society at large. "It is," said one lecturer in nursing who didn't want to be named, "not uncommon for a student nurse to have to be told that she should not text her friends while standing at a patient's bedside. Most of my colleagues," she said, "who teach pre-registration nursing find this is a huge problem."

You can't, points out Liz Fradd, who was awarded a DBE three years ago for her services to nursing, "expect people to have a particular attitude, which we think is the right attitude, when they have no experience of, for example, elderly people being treated with dignity." Even those who go into nursing because they want to provide compassionate care often find themselves becoming "socialised", as another lecturer in nursing put it, into systems and cultures that make this difficult. "While at university," said one staff nurse, "several lecturers mentioned the adoption of the culture, and the importance of not accepting it. This," he added, "seemingly is a long-standing problem."

It certainly seems to be. Audrey Emerton, a cross-bencher in the House of Lords who qualified as a nurse in the 1950s, has lived through more scandals in nursing care than she can remember. "All of them," she told me, "came up with the same findings in the end. Last year," she said, "I went back to look at the 30 recommendations to see what was common to all of them, and it came to me that it was culture."

Culture isn't something you change overnight, but plenty of people are trying. Jocelyn Cornwell, at the King's Fund, has started a programme called Point of Care: a mix, she told me, of "research and writing, working with hospitals, and trying to make a difference". It draws on models that have worked successfully elsewhere, like the Schwartz Rounds developed at Massachusetts General Hospital, where "care-givers from different disciplines come together to discuss difficult emotional and social issues arising from patient care". It's also exploring the idea of "intentional rounding", where nurses don't wait for patients to press their buzzer, but visit them every hour to see what they need. The results, she says, are "encouraging".

Aidan Halligan, a former deputy chief medical officer for England who's now director of education at University College London Hospitals, says that "culture management" is as important as "performance management". He has developed a "learning hospital" on the site, which replicates every aspect of the design of the main hospital, where staff are filmed interacting with each other. The aim, he says, is to "influence attitudes and behaviours".

The learning hospital offers short training programmes for staff across the medical and nursing spectrum, including one called the ward safety checklist, which aims to improve communication between all the people involved in a patient's care. The programme, he told me, when I met him to look round, can be an emotional experience for staff with "a high level of frustration", who are "desperate to do things better". When I went back to take part in one, with consultants, junior doctors and nurses from UCH, I could see how it might make a difference. But two days after the Milly Dowler hacking scandal broke wasn't an ideal time for members of a profession under siege to open their hearts to a hack.

The Patients Association, in conjunction with the Nursing Standard, called an emergency meeting last October to discuss poor nursing care. They invited 45 people from inside the NHS, and organisations which work with it, and one or two interested outsiders, like me. When the group was asked if they felt nursing was the main problem with patient care, only two or three of us put up our hands. Nicola Ranger, deputy chief nurse at UCH, was one of them. "The public has genuinely lost confidence in our profession," she told me afterwards. She was, she said, irritated by "the moan culture" among some nurses. "We need to have slightly more honest conversations with people. If you really don't like it there are other jobs out there, and I bet you within a year you'll come back and tell me, actually, I have eight weeks' holiday, I'm paid well on the whole, it's not all bad."

The Patients Association, with the Nursing Standard, has launched a two-year "care campaign" to address the issue of poor patient care, and also a four-point tool it's calling the "CARE challenge". It wants patients, relatives and nurses to use the "care slogan" it has come up with as a checklist for the basics of care that patients so often say are missing. It wants nurses to remember that they should Communicate with compassion; Assist with toileting, ensuring dignity; Relieve pain effectively; and Encourage adequate nutrition. It wants to highlight the obstacles nurses face in giving basic care, and support nurses who speak out about those who fail to do it.

There's certainly a lot to be said for simplicity, and if the simple measures mentioned in the slogan were adopted on a mass scale, they would surely make a difference. But compassion, and "communicating with compassion", isn't always simple. It is, says Andy Bradley, a former care assistant who contacted me after hearing my programme,"demanding" and "requires discipline and practice". He has, he told me, started an organisation called frameworks4change, which aims to put compassion "at the heart of the nurse/patient relationship".

Bradley grew up in a care home for people with dementia run by his mother, a "compassionate life-long nurse". When he got a job as a care assistant himself, working with people with complex disabilities, he was shocked by the attitudes and behaviour of some of his colleagues. Now, he runs courses in "the compassionate practitioner" for people working in care homes, local authorities and NHS trusts.

The courses are proving popular with the staff and, of course, with their patients. "The response from one of my patients," said one nurse working with dementia patients in Essex, "was that it felt like he was being cared for by a friend rather than just a technician." Bradley was recently picked by The Observer as one of its "top 50 radicals", and featured on BBC Breakfast and Radio 4's The World Tonight. He wants, he says, to change the whole culture of nursing, which is certainly aiming high. But he's confident he can do it. "As a result of these programmes," he says, "there are real and lasting changes in the care given. There's a kind of ripple effect that touches all those in the organisation."

I don't doubt that compassionate care can ripple out, and even up, but I can't help thinking that cultures are usually set from the top. Liz Fradd agrees. "In any organisation," she says, "you'll find pockets of good and pockets of less good, but fundamentally the thing that really matters are the people at the top. If they're not a compassionate board, if they don't empower, encourage, support and enable staff, how can they possibly do that for their patients? If you use the John Lewis example, their internal mantra is all about the staff coming first. If you treat the staff well, they'll treat the customers well, and I think that's what we've got to get right in healthcare."

Dame Liz, who helped establish the Care Quality Commission and has been doing inspection and review work for many years, has been working with Baroness Emerton and others to try to get ministers – and organisations – to accept that "this is not just about individuals". They have, she told me, developed a "self-assessment tool", which they're calling a "cultural barometer", to help people reflect on what the culture in their organisation is like.

The work is now being developed by researchers at King's College, and has been used "in its very raw state" by the NHS Confederation in its commission on dignity. The point, she says, is, "for people to use it for their personal self-reflection, and then to build up some influence inside their organisation."

What it all seems to come down to is good leaders, who set good examples, and hold the staff they're managing to account. Compassion is what we all want, but it can't, as Nicola Ranger points out, "be emotional with every single patient". If it's going to "come from in here", she said, tapping her heart, "that's great". But "if it doesn't let's have a code of behaviour. It's a code of behaviour that, when you walk on that ward, has got to be the standard."

I think she's right. Let's, by all means, train people in compassion. But when I was in hospital I'd have settled for good care, and good manners.

Tomorrow: Part 4 - How to make a difference: A day in a hospital that shows what works

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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