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What’s the matter with nursing?

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25 July, 2011

“What’s the matter with nursing?” cried a BMJ editorial a few weeks ago. Just about everyone seems to have a view, with many commentators looking for a scapegoat or a quick fix. Many of my friends know exactly what’s wrong. They don’t make nurses like they used to. In our day…

Well, it’s easy to hark back to a golden age, but I would challenge anyone who does to think carefully about the workload, staffing and challenges of modern healthcare. Most wards have significant numbers of chronically sick, frail and vulnerable patients. Many nurses work on wards that are not fit for purpose, with staffing levels that have not changed in years. Many of you describe your working life as a war zone. And this week we learnt that ward sisters in some hospitals spent 40% of their time on bureaucracy.

Most of the criticism levelled at nurses relates the essential care given to dependent older people.

So let’s be honest about how we care for older people. Although there are many individual examples of excellent care, there has never been a golden age. I remember the warehouse-like Nightingale geriatric wards during my training in the early 1980s. In the 1990s, I took over management of a rehabilitation hospital where communal toileting, communal clothing and milk and sugar in the tea pot were standard practices. When I asked staff why they did this they were happy to explain. The toilets were difficult to access with a wheelchair; patients’ clothes got lost so it was better to use the hospital ones; and it was quicker to put everything in one pot than ask patients’ preferences since most had dementia.

Scary stuff for a newly appointed senior nurse.

I learnt how easily staff lose sight of what they were doing and why. If we put nurses in silos, give them little education, no feedback, and an inappropriate skill mix they will cut corners. Deidre Wild, a nurse researcher with a passion for care of older people describes it as caring for, rather than about, patients. Getting the job done, rather than thinking about how best to do it, becomes the priority.

My staff worked in a vacuum. What was missing was a crucial element - strong clinical leadership provided by empowered, skilled and enthusiastic ward sisters.

The ward sisters who inspired me to be the best nurse I could be weren’t in the office doing the paperwork but equally they weren’t mucking in. They worked as role models alongside staff, facilitating, challenging, managing and developing every member of the team. This role is for nurses at the top of their game, who can teach, inspire and develop our next generation.

Everyone knows ward sisters hold the key, but is there a will to make the organisational change and investment to ensure we keep our best nurses close to the bedside? If we don’t do this what is the alternative?

Readers' comments (3)

  • This is a really interesting article. What's wrong with Nursing? I really don't know where to start on that one!

    First of all I do not think on the whole it is the Nurses themselves. Older Nurses or newly qualified, it makes no difference. We all essentially go into Nursing (and stick with it) for pretty much the same reasons, regardless of the practices that we each have or used to or currently work with.

    I think what is wrong with Nursing now is predominantly the system in which we are forced to work within. As the article says, many of our workplaces are 'war zones'. We have chronic underfunding, chronic understaffing and chronic bed shortages for far too many patients to deal with, the majority of our time is now taken up dealing with paperwork, brush fires, bed managers, admin, basically everything that takes us AWAY from treating and caring for our patients. The working practices that endemically facilitate unhealthy work practices and high stress levels but do little to look after it's own workforce are a massive problem. There is no focus on post grad or continuing training. Many of us are burned out far too quickly, and yet we still have to deal with far too little pay, constant attcks on our pensions/increments/etc.

    I do however think a lot of the time Nurses are our own worst enemy. The image of our profession is one that we all have to deal with because it allows conditions like those above to be forced upon us, (we are not worth paying a decent wage or given extra training are we, we are just Nurses), yet Nurses on the whole do not stand up for ourselves or our profession. We as a profession have been too passive, too willing to just 'get our heads down' and fight and bitch amongst ourselves for far too long.

    Strong, effective leadership is only part of the solution to this. It isn't ward sisters that hold the key at all, it is each and every Nurse, from newly qualified staff Nurse right up to the ENP's and specialist Nurses. Each individual Nurse has to be more willing to take on that role, to fight for our profession and our patients. Only then can we force a change.

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  • excellent article and excellent follow up first comment by Mike, and hard to follow further, but I wish to have a try.

    I like the analogy of the workplaces we are forced to work in to 'war zones', This is a perfect description in many areas.

    It all sounds like the concept of general management of the NHS gone totally awry. This method of management embraces all aspects of healthcare and the resources required to deliver it. One of its main tenets, and actual fact of the matter, is that its most valuable resource, its most costly, and one of its largest (besides its land, buildings and ? financial reserves) is - guess what? - its staff, and in order for them to function effectively they need to be looked after, respected as individuals, offered incentives such as an agreeable and safe workplace, a reasonable sized and interesting work load, motivation, recognition, acknowledgement, further education, training and development appropriate to their area of work, a system of evaluation, a career structure with opportunities for promotion, occupational health, managerial and peer support system, ideally facilities for recreation and periods of rest, hygienic changing facilities with personal lockers, and showers, a laundry and last but not least a good employment package in accordance with the law which includes an appropriate salary structure and pension scheme. Logically it could be concluded that staff are only as good as the way they are treated, except in the case of nurses who give far, far more than they ever receive from many of their employers who do not seem to realise their staff have needs as much as those they are serving.

    Almost endless books have been written on the workings of this style of management with its pros and cons.

    As for leadership, I agree with your last paragraph, in addition to all you write above Mark, and leading must not only be from the top down but is more effective when it also comes from the very bottom up to provide a balance, where everybody is responsible for their own role, to their colleagues, to their managers, to the organisation, to everybody they come into contact with in their day's work and above all to their patients and their families and visitors to the ward.

    In this manner everybody is less stressed, works more efficiently, makes fewer errors and with enjoyment to everybody's benefit. But could such idealism ever come to pass ever again as in the good old days before general management and when clinical management was at the forefront of direct patient care?

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  • Mike and anonymous say it all!!!!

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