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Dean Royles: 'This constant infighting makes it easy to pick off nurses'

Nurses have taken the brunt of the criticism surrounding Mid Staffs, says Dean Royles

Recent weeks have been tough for the NHS and for all of us who work in it. The Francis report, the public inquiry into the sad events at Mid Staffordshire Foundation Trust, found failings from the top to bottom of the NHS. Organisations, individuals, clinicians and medics, managers and administrators have all been found wanting.

Like many in the NHS, I spent the last few weeks with a knot in the pit of my stomach. What would the report say? Would the recommendations make sense? Where would the finger be pointed?

As it happens Francis came out saying that we shouldn’t be looking for scapegoats. It seemed a smart move. It means we can all own the report. We don’t need to be defensive. We can look at the recommendations and consider if they make sense both intuitively and practically and then move on with pace and purpose and start making changes.

A nurse on twitter said she had been “emboldened” by Francis. It’s a great reaction. The approach to blame avoidance almost worked. There was some rational commentary but pretty soon we saw the need in the media to identify a simpler solution than the 290 recommendations, and it seems to me nurses and nursing has taken the brunt of the criticism.

“As it happens Francis came out saying that we shouldn’t be looking for scapegoats. It seemed a smart move. It means we can all own the report”

The NHS has had a number of inquiries into patient care issues, such as Bristol and Alder Hey, but I don’t recall nurses being held so central and so vilified by some of the commentary. Take this example from the Telegraph on Friday 7 February:

“So now we know. Britain’s nurses and doctors are as bad as Britain’s bankers. Our angels in white are just as selfish, just as arrogant and manipulative and secretive, as the barrow-boys in pinstripes. In fact, in many ways they’re worse. The bankers bled the country dry, but to my knowledge they didn’t kill anybody. The death toll at Mid Staffs is placed at 1,200 victims. And that may be a conservative estimate.”

It’s shocking isn’t it, but is it surprising that someone wrote it? And that it was published in a national newspaper? No, it isn’t because for too long the NHS has tolerated and exacerbated professional factions. Doctors blame nurses, nurses blame doctors, clinicians blame administrators and managers blame staff. The only time we agree is when everyone is blaming politicians. It has to stop.

It is hardly surprising when we have this constant infighting that it becomes easy for others to pick off a particular group and the rest of us find it easier to join in. It’s not fair, not professional and certainly does the NHS and patients as a whole a disservice. None of us, neither managers nor clinicians, looks big by making another group look small. It just adds to a picture of disfunctionality.

As a human resources professional working in the NHS, you get to see the very best in people, the very best in our staff. Day in and day out in our hospitals, in our community services, in our GP practices and our mental health services. For those not working in the NHS you only have to watch reality TV programmes set in accident and emergency departments or maternity wards to see examples of unfailing compassion, bravery and the exercise of incredible skill, knowledge and expertise. Saving lives and bringing hope to people where care and compassion are what matter most. It makes me incredibly proud of the NHS and of its staff and the environment that makes this commonplace.

These innumerable acts of kindness, empathy and healing don’t make the news headlines or generate inquiries. But it is right that, even in the midst of making sense about Stafford Hospital, we acknowledge and recognise this element of our NHS and the staff (and managers) that make it happen.

In HR you are also exposed to the situations where it goes wrong, whether through staff conduct, capability issues or sometimes though having insufficient resources at the right time. In the NHS this is always traumatic, always painful and can sometimes affect your belief in the generosity of the human condition. But the fact that I know about these and I know most nurses do too, reassures me that we have been addressing poor performance. We can of course do this better and more consistently. Francis will see organisations fundamentally examine all their people management practices from recruitment through appraisal and development to performance management.

There has also been a lot of speculation that increased educational requirements is responsible for a lack of compassion. How bizarre. If this were true, wouldn’t the same apply to doctors, speech therapists, dietitians and pharmacists? We have to move on from this debate.

One of the problems we now face is the perception that poor care is the result of wilful neglect but that great care happens by accident. It doesn’t. It takes time, effort and commitment and good leadership on the board and on the ward. It is this that gives the NHS some enviable patient satisfaction results. And the backbone of this great care are nurses.

I work in the NHS because over the years I’ve been inspired by nursing staff. From the healthcare assistant that lived on my street when I was a child, who all the neighbours looked to for guidance and information, to the nurses I met as a human resources manager sharing the copious amount of chocolates they received in thanks from grateful patients, and proudly showing me the noticeboard full of thank-you letters.

From the midwives that skilfully delivered my four children to the directors of nurses I now work with, who are determined to use Francis to drive the world-class staff engagement we will need if we are to turn Francis into a byword for improvement rather than failure.

Dean Royles is director of the NHS Employers organisation

Readers' comments (31)

  • Pirate and Parrot

    Would the recommendations make sense?

    Yes, they make sense to me !


    'Doctors blame nurses, nurses blame doctors, clinicians blame administrators and managers blame staff. The only time we agree is when everyone is blaming politicians. It has to stop.'

    Indeed - patient care, can get lost on that particular battlefield !

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  • ...and patients and the public can blame the lot. it sure does waste a lot of time, energy and costs which could be more 'profitably', and more importantly beneficially, spent on patient care!

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  • michael stone

    The achieving of 'coherent behaviour' inside the NHS, is hugely challenging - it definitely tends to be absent at present.

    My own issue (home end-of-life care) requires joined-up behaviour all of the way from GP to (potentially) police officers: if the staff inside a single hospital can't get it right, I'm not surprised that I'm having so many problems improving that area !

    And Francis did not place most of the blame on nurses - how come so many nurses, seem to think he did ? Or do nurses just think that the media are blaming them in relative isolation ? The media I read (not the tabloids) and listen to (Radio 4) are not isolating nurses for blame, so far as I can tell.

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  • Hello Mike. Nurses are getting a lot of stick because managers aren't regulated, they were responsible for most of what went wrong, NONE of them have had any sanctions, many have actually been promoted (I met one in my local health economy had was literally speechless at the brass neck of the man) and the whole thing is skewed at the professions not the culture. You can only change that if you start by changing the people at the top and my biggest disappointment in the whole report is how he bottled it/ had political pressure not to call for some key resignations.

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  • The Nobody | 16-Feb-2013 8:12 pm

    are there no clinical managers in any of these posts?

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  • There are two newspapers that seem to want to turn the nation against nurses, that is what has to stop. I don't know how their editors allow them to publish some of their stories.

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  • Anonymous | 17-Feb-2013 10:06 am

    if the reports are true they need to be brought to public attention. those which are not need to be suppressed.

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  • Journalism is like nursing. Much is of a very high which is invaluable to society, some is of very poor quality which should be eliminated, and then there is all of the practice in between which is passable but requires discernment on the part of its consumers.

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  • not all british nurses and doctors are bad, that is what is so disheartening.

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  • 10 staff at team brief 3 go home from nightshift ,sister goes to office or meeting takes deputy with her, 2 registered nurses giving medication to 24 patients leaves 3 hca to assist patients wash dress eat breakfast go to toilet. 1 goes on escort . Staff ratio is a joke the ratio is what the managers say it is. The patients don't matter and neither do the staff so suck it up and get on with it. Or say your piece and then do your best.

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  • Re DH Agent comment above - I too listen to R4 but you must have missed the part where John Humphrey's blamed the educational levels for the "fact" that nurses "now show no compassion and caring." The RCN representative was continually interrupted and shouted down by the odious self important Humphrey's. And the tabloids are not necessarily to blame, the excerpt above came from the Telegraph.
    Maybe its more the conservative right from whatever sphere who are systematically attacking nurses for having the audacity to try and improve their skills, education and position instead of marrying well to do young men (ie doctors) and mopping the brows of the middle classes and sacrificing themselves for the poor. The exasperation in the right wing press is palpable when they report our pay.

    The staff/patient ratio is a large part of the problem; worn out nurses being pulled in 3 different directions at once and having to document everything that is said or done to protect themselves against spurious and vexatious complaints.
    Nurses are easy targets. We are in the forefront, we have very little clout, and are likely to stay that way whilst we stand around wringing our hands in exasperation. Nursing is not valued by the public, whose anger is focused on the lack of staff for basic tasks and the need to complete paperwork, which is not considered important. Many complaints make sweeping comments such as "she didnt care" and "did'nt smile" because they have a pre conceived idea that all nurses are like pollyanna and have no personal need or family commitments to consider.

    I used to be proud to be a nurse, but this recent onslaught by the media and the public's obscured idea that I am "above myself" as I should only be there to be their doctor's handmaiden is becoming nauseating, and I have felt myself becoming insular and quite depressed at the situation.
    I have mentored many student nurses, some of them weren't suitable for the area (ED), some of them had different outlooks and some I didn't like very much; but I really dont remember any that didn't care!

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  • It's all too easy to blame the nurses because they don't stand up for themselves and fight back. Sadly, nurses are the scapegoat for anyone wanting to point the finger of blame.

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  • Nurses are easy to blame and to scapegoat.
    They are the public face of the hospital, they are the staff the patients most often speak to.

    Yet the public have no idea what a nurse's role actually is. And the NHS and the trusts have never told the public either.

    Actually considering how much nurses have been attacked lately, the NHS has kept very quiet about their roles. Its like a vacuum has emerged and all the newspapers are filling it.

    I don't notice the RCN are rebutting what the newspapers say, do you? If newspapers had published articles about doctors, the GMC would complain.

    I honestly think you're being bullied and its so awful.

    I personally think nurses are lovely and amazing

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  • Anonymous | 16-Feb-2013 8:20 pm

    Yes there were, but they were in a minority.
    I am a manager not a clinician. I've never understood why senior nurses don't speak up, until I saw the savage mobbing (not bullying, it's larger scale) for myself first hand. Thankfully not at my trust, but it was an eye opener.

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  • The Nobody | 18-Feb-2013 8:46 pm

    what I don't understand is why master's courses in healthcare management are offered to clinicians when most of the managers are non-clinical. how can managers who are unfamiliar with the work of nurses manage their work and be in charge of patient care and the resources this requires?

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  • It is ridiculous, I agree. Clinicians do a much better job of managing clinicians. I used to work in a lab and was much happier managing them because I knew how long things took and how things worked.
    I'm sure I may get flamed for this, but one of the reasons some organisations think managers are better is because of what underpins qualifications like an MBA. (Which of course ignores the most important difference, patients are people, not widgets in a factory) - which includes the theory and practice of running factories, supply chain, logistics and so on. In the same way that an experienced nurse will ask a patient in A&E what medicines they're taking or what their symptoms were and so on - and get straight to the heart of what's wrong, there are management things which help you do the same for e.g. a struggling business or a failing shop or a problem in supply.
    I'm not remotely saying this translates well to the NHS, I'm just saying that a bit like physiology there are similar things in management that help you diagnose. Classic case of management trainees that might know all the answers on paper but can't talk to people and have no experience.
    I was so shocked when I came to the NHS, I thought clinicians led the service and we managers ran along behind sorting out your spreadsheets and whatever you needed.
    That's what it should be and I hope the Francis report drives that change. I would love to work for a senior nurse as her/ his gopher, not an accountant, as I do now.

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  • The Nobody | 18-Feb-2013 10:56 pm

    Master of Science Degree in Healthcare Management is the healthcare equivalent of an MBA but more specific to the management of the NHS, and other health services, than the MBA which is, as you say, more business orientated. The degree course is open to all qualified health care professionals with the relevant clinical experience.

    It just seems that most NHS managers hold an MBA rather than this more clinically oriented degree and if this is so I wonder why this is?

    Clinicians holding this degree are specialists in their own field but should be able to rely on the expertise of all those they are managing whether in clinical areas or administrative departments as well as offering support to their staff and providing them with support they need, including physical and material resources. This means listening to the advice of their staff regarding their needs for their patients in their care and trusting them to make clinical decisions and do the job they have been trained for. This also includes taking their advice on the type and number of staff they need as it is the front line staff who are best placed to judge this. The work is that of a team where everybody participates in equal partnership to ensure the highest standards of care.

    This concept should help to eliminate many of the current problems of communication, poor working environment, poor team working, difficult relationships between staff, and inequalities in staffing levels across the services and concentrate instead on motivating staff at every level to provide services of the best possible quality.

    Maybe it sounds idealistic but it is disappointing that there are apparently not the jobs available for healthcare professionals holding these qualifications and the relevant experience.

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  • I agree with above. Frontline Clinicians with relevant master's degrees are given no credibility by managers and are not treated as experts. This is to maintain the status quo, and make sure that "managers" are on higher pay grades, and treated as more important than clinicians. They will only promote those who collude in this fallacy, thus maintaining the status quo. How long does it take to learn how to interpret a spreadsheet or allocate budgets? Most people could learn this in a much quicker time than it would take to become any sort of clinical expert. In this way, patient care is devalued in society and in parts of the health service. "Matrons" and "ward managers" should spend a substantial part of their time working clinically, unless this is not important enough.

    The article above is thoughtful and reflective and does not tally with how many HR "managers" actually work.

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  • carrie-ann | 19-Feb-2013 11:22 am

    assuming all MSc Healthcare Management courses have the same core modules, you may already know that nurses holding this degree are usually well trained in financial management to read the trust balance sheets too, as well as managing budgets, resources and leading teams and motivating staff to lead from the bottom up as well as the top down in order to share ideas, pool skills and discuss best practice and eliminate any issues which may impact on substandard care with the aim of providing the highest quality of care. This means everybody, including the manager, delivering bedside care and sharing all the work on the ward.

    Together with their clinical skills and experience this may be a double advantage (and two jobs for the price of one!). I outline the course below for The Nobody, NHS Manager.

    The Nobody | 18-Feb-2013 10:56 pm

    from Anonymous | 18-Feb-2013 11:52 pm and writer of the two previous comments on the same topic

    Those who hold an MSc Healthcare Management Degree are not only highly experienced clinicians in their field who may also have undergone other clinical and related training, but have also followed a programme such as shown in the example below from one UK university. However, little interest seems to be shown by the NHS who offer few opportunities of employment at this level except to those already working in managerial positions within the organisation. Although it is claimed to have international recognition there are some countries who do not accept is as vocational training in addition to a nursing, medical or other healthcare professional qualification.

    “This programme aims to provide a high-quality, vocational education, which is intellectually rigorous and up-to-date, as well as relevant to the needs of existing and future managers, executives and clinicians in the healthcare sector.

    The programme has a business management orientation and draws on a broad base of management theory and examples to explain and analyse the sector. It is designed to provide participants with concepts, models, techniques and examples, which will enable them to improve the provision of care to patients.
    It is based on specially designed modules to give students a thorough grounding in the basic management disciplines, followed by specialist modules in particular aspects of healthcare management.”

    “Compulsory Modules

    • Operational Management in Health Care
    • Financial Management
    • Health Care Quality Management
    • Health Care Systems, Structures and Functions
    • Organisational Behaviour
    • Professionals in Health Care
    • Health Economics
    • Research Methods
    • 5,000-word dissertation

    Module Overview
    This programme comprises eight taught modules and a research-based dissertation.

    Compulsory Modules

    Operational Management in Health Care
    This module provides detailed insights into the concepts of managing and developing people and services. These concepts are operationalised into the management challenges of running a successful health service, and the personal development skills needed for managing change and innovation.

    Financial Management
    This module provides the foundations for understanding, analysing and interpreting financial information, and enables you to apply accounting principles and financial theory across management disciplines and organisations.

    Health Care Quality Management
    This module explores the socially constructed and therefore contested nature of health care quality and examines the implications this has for service delivery and continuous quality improvement. It focuses on management as a means to achieve quality standards and patient satisfaction.

    Health Care Systems, Structures and Functions
    This module explores the complex management and administrative demands of a modern health system. Its role in the programme is to apply the general management principles, learned in other prescribed modules, to health care.

    Organisational Behaviour
    This module integrates the study of forms, structures and processes of organisations with the human aspects of psychology at work. The module provides an insight into the fundamentals on which organisations are built and provides analytical processes for understanding behaviour at work and managerial processes.

    Professionals in Health Care
    An issue in all health care systems is that of working with, managing and developing professionals. This module explores a wide range of issues associated with professionals, professionalisation and organisational learning.

    Health Economics
    This module will introduce health economics and explore the notion of scarcity, which is as relevant in the health sector as it is in others. Whatever the level of expenditure on health care, there will always be unmet demand and it is important that these resources are applied in the best ways possible. It covers the use of markets as an allocation mechanism and looks at a range of economic evaluation methods for decision making by managers and policy makers.

    Research Methods
    Introducing the process of research project formulation and the key elements of research design, this module will prepare you to design and execute their research study for their dissertation in a systematic and scientific manner.”

    The Department of Health Care Management and Policy is part of the Faculty of Business, Economics and Law.

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  • I find this fascinating and scary. In my play the managers and a matron who became a manager never ever visit the wards as they are scared at what they will actually find.

    Are managers too scared visit wards?
    They sit in their offices all day and do whatever they do. Its as if they know they will not like what they see on the wards so they hide away. They know if they communicated with the nurses they will not like what they hear.

    Looking at spreadsheets if much easier and simpler then dealing with a nurse who tells you the ward is short staffed and she needs supporting to care properly.

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