Elaine Maxwell: 'Signing up to a set of values is not enough to transform care'
Most healthcare workers would claim they already share the 6Cs, says Elaine Maxwell
The consultation on the new vision for nurses, midwives and caregivers in England, drawn up by the chief nursing officer for England and the director of nursing at the Department of Health, has recently come to a close.
This is the latest in a line of strategies, including the Prime Minister’s Commission on the Future of Nursing and Midwifery in England in 2010 and the Nursing and Care Quality Forum in 2012. Will this one be more successful?
This vision outlines six values (the 6Cs - care, communication, compassion, courage, commitment and competency) and six areas for action. The action areas outline the outcomes, and the values outline how practice should be delivered.
What is notable by its absence in this vision, however, is a description of what nurses, midwives and caregivers should actually do.
Defining nursing by the way it is practised rather than its unique contribution to the multidisciplinary team has been fashionable in the wake of inquiries such as those at Mid Staffordshire Foundation Trust and Winterbourne View. The new vision appears to imply that by recruiting people with the right values, care standards will automatically be met.
Most healthcare workers would claim they already share these values. However, care is provided by teams rather than individuals, and problems often arise at the system level. There is strong evidence that individuals are socialised into conforming to existing team or unit norms. Team norms are often a pragmatic response to the need to manage work demands with the resources available, often with competing priorities, rather than an abstract set of values.
“Care is provided by teams rather than individuals, and problems often arise at the system level”
Changes in the way in which healthcare is delivered significantly affect the demands placed on nurses, midwives and healthcare assistants. Faster throughput of patients, increasing numbers of older patients with multiple comorbidities and new technology have all changed patient pathways within and outside hospitals.
These changes have created additional demands, with invisible and underestimated consequences for how care is delivered. The lack of attention to these changes has led in many cases to nurses continuing to deliver care in a traditional model but with insufficient staff to meet demands and therefore the same standards. Nurses have to compromise to make the best fit between demand and available staff, often leading to high levels of stress, which in turn leads to burnout. This makes it even harder to practise in line with the values and, ultimately, contributes to a drop in care standards.
The pace of change is continuing to increase as the government’s Quality, Innovation, Productivity and Prevention programme seeks to improve the quality of care while saving up to £20bn by 2015.
Achieving this requires a reinterpretation of the practice of registered and unregistered staff. Clarity about their contribution is pivotal to embedding the 6C values and will provide the logic for determining the optimum numbers of nurses, midwives and healthcare assistants with the right skills to complement the rest of the team. Where there are clear expectations and sufficient staff to deliver them, leaders can set and enforce realistic team norms that match the desired values.
Rather than exhort individuals to sign up to a set of values and outcomes, what is needed is a vision that explores how nurses, midwives and healthcare assistants will contribute to redesigned care pathways and how they will need to adapt their practice to maintain care standards.
Elaine Maxwell is assistant director at The Health Foundation