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How the 6Cs relate to clinical leaders


A new vision and strategy calls for nursing and midwifery leaders to become role models by embracing its core values and behaviours

In this article…

  • The 6Cs and how they relate to leadership in nursing and midwifery
  • Challenges facing leaders in carrying out the new vision
  • The importance of commitment to carry out changes
  • This article has been double-blind peer reviewed
  • Figures and tables can be seen in the attached print-friendly PDF file of the complete article in the ‘Files’ section of this page


David Foster is deputy director of nursing at the Department of Health.


Foster D (2013) How the 6Cs relate to clinical leaders. Nursing Times; 109; 1/2: 12-13.

  • Compassion in Practice, the new strategy for nurses, midwives and care staff, will build on strengths already established within the NHS, and address its failings. Clinical leaders can help to achieve the vision by embracing its principles and acting as role models to motivate their staff.

5 key points

  1. Nursing and midwifery need to develop a culture of compassionate care
  2. Strong clinical leadership in all parts of the health and care system is vital
  3. Clinical leaders need to become role models of the 6Cs
  4. Leaders need to create a culture of continuing personal and professional development
  5. The professions need listening leaders who are receptive and responsive, act appropriately and make whistleblowing unnecessary

The nursing professions have come in for a great deal of criticism over recent years, and while not all of it has been justified, we must accept that some appalling failures have led many people to lose trust in the care we give. To regain that trust we need to be clear about the values and behaviours required of all nurses, midwives and care-givers if we are to provide the skilled and compassionate care our patients deserve.

A new three-year strategy and vision has defined these values and behaviours and the steps we must take to ensure they are embedded in all areas of health, public health and social care services (Cummings and Bennett, 2012). The vision is based on the premise that we need to develop a culture of compassionate care.

A core aspect of the vision, which was developed in partnership with frontline staff, patients, and the public, is the 6Cs. We believe these encapsulate the core values of nursing - and are equally relevant to other health professions:

  • Care;
  • Compassion;
  • Competence;
  • Communication;
  • Courage;
  • Commitment.

Most nursing care is excellent, but when it falls below acceptable standards we have to take action rather than excuse it. Some of the worst examples to recently emerge can be described as a betrayal - of both patients and fellow professionals. In order to take action we need strong clinical and managerial leaders who can show by example that the 6Cs are relevant to all aspects of nursing, midwifery and caregiving.


Delivering high-quality care is our goal - and most of the time we achieve it, but challenges and pressures can compromise our intentions. While caring is rewarding it is also demanding; it takes a great deal of effort to get every interaction exactly right, especially in complex situations.

However, get it right we must, making every contact count - and this is as true for whole organisations as it is for individual practitioners. The quality of care must be a priority not only for directors of nursing, but for all directors: there is a shared corporate responsibility and accountability at board level for the quality of care delivered.

We need both personal and corporate understanding of and confidence in what constitutes high-quality care. Without a clear vision of what we are aiming to achieve across all NHS-funded care we cannot guard against settling for “good enough”. There are many tools that measure quality, and we should use them across the NHS and care system so that all health and care professionals can measure their own performance against required standards.

However, while tools can measure some aspects of quality, others cannot be measured. I saw this first-hand when my father was in hospital and nearing the end of his life. He needed pain relief and the nurse who gave him his final injection of diamorphine kissed him on the forehead.

I was slightly taken aback by this intimacy, but she and my father had developed a relationship over a number of weeks that made this an acceptable way to say goodbye. So despite the need for evidence, audit and other measureable outcomes, it is important, in a sensitively judged way, to demonstrate that you care.


Compassion is an innate quality that individuals have in varying degrees, and how we demonstrate it is a personal thing. Using the language of compassion to describe our business of caring is likely to conflict with some of the language used by those whose focus is on financial considerations. While we must use compassion as a driving principle of caring, we also need to be aware of the need to be efficient and effective.

There is a risk that the word compassion will become ubiquitous, so we must ensure care with compassion does not become a superficial and hollow mantra, because compassion is a complex concept. If we accept that compassion is innate any human being should be able to demonstrate it, but as nurses, midwives and care staff, we have special expectations placed on us to demonstrate our compassion at all times.

If compassion is to be embedded in care it must be role modelled, especially by those in leadership roles. Demonstrating empathy, kindness and respect, and treating people with dignity at all times takes effort and energy, and our actions are constantly scrutinised. The staff we lead will rightly be critical if we fail to show the compassion we expect of them.

This includes recognising that the emotional labour of caring is highly demanding, and that we have a duty to support each other. No one has an inexhaustible supply of compassion, and we need to spot the signs of stress and support each other through difficult times.


While care without compassion is unacceptable, care without knowledge is dangerous. Skills and knowledge underpin all our interactions but the care we give must be intelligent care, not ritualistic but thoughtful, personalised, safe and driven by evidence. As a profession we should not be shy of developing and expressing expert knowledge. This is not to suggest that

everyone needs to become a specialist, but we should perhaps do more to celebrate the expertise of experienced general nurses.

Individuals’ ability to deliver the highest standards of care needs to be regularly assessed through appraisal, peer review and reflective clinical supervision - and supported through training and development to address any shortcomings. This causes me to reflect on my own performance as an inexperienced charge nurse.

When I began appraising, mentoring and coaching, there was a strong temptation to be critical rather than nurturing, motivating and supportive. I quickly found that this latter approach is far more likely to result in competent, confident and motivated staff.

It is important to recognise that once competent does not mean forever competent, so we should never assume that staff retain their skills throughout their careers. Clinical and social care leaders must make development the norm by creating organisational cultures that value continuing personal and professional development, and create responsive, flexible and cost-effective opportunities for career-long learning.


Communication is a complex art. For leaders it is as much about being receptive to feedback as it is about keeping people informed. Leaders must also ensure their staff appreciate that what may seem like simple information to us is often complex and daunting for those in our care. If we are to adhere to the principle that there should be “no decision about me without me” we must ensure that people understand the information they need in order to make informed choices and become active participants in their care.

Workload pressures can conspire against good communication, and demonstrating empathy by trying to put ourselves in the position of those in our care is challenging. However, we constantly need to remind ourselves that what we have said is not necessarily what has been heard or retained.

Our communication techniques must also reflect the diversity of the people accessing our services, taking into account culture, languages and other needs. The leadership challenge is balancing effort and effectiveness and ensuring people have a positive understanding of their care.


Being courageous is not just about doing the right thing or speaking up when things go wrong; it also gives us a licence to be creative, to innovate and challenge the status quo. Leaders face the challenge of managing risks with the maturity that enables others to lead, be bold, original and stimulate change, while allowing and even supporting failure.

Speaking out when things go wrong takes courage. We have to challenge poor care when we see it, to advocate for those who cannot speak for themselves. While we need to create a culture where whistleblowing is supported, it is more important to develop listening leaders who are receptive and responsive, act appropriately when concerns are raised internally and make whistleblowing unnecessary.

There is also a political dimension to courage, and senior leaders in particular will need the courage to generate and lead significant change. This may involve redesigning services locally or reconfiguring entire facilities and services over a wider area. Courage in contentious situations will need leaders to unite, and to be focused and supportive of each other and their teams.


Demonstrating commitment by acting as exemplary role models will make this vision of nursing, midwifery and care-giving real to frontline staff, giving it personal and professional resonance. We need to live the values and behaviours it encapsulates, and while doing that day in and day out will not be easy, we cannot be

half-hearted. Part of our commitment must be to provide enthusiastic and accountable leadership in which we are all committed to the actions underpinning the vision and implementing them effectively. While this is important to our professions it is vital to those in our care. If care is our business, then excellent care must be our commitment.


Developing a culture of compassionate care does not mean starting from a blank page. We have much to be proud of and much to build upon to make all aspects of our care of a consistently high standard.

These are undoubtedly challenging times for nurses, midwives and care staff, but as individuals and collectively, we can rise to the challenges and demonstrate the leadership the people in our care deserve.

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Readers' comments (3)

  • A well thought out and accessible article and I don't disagree with anything that has been said.

    For this to be more than just another piece of rhetoric though, it needs staff at all levels to behave with courage and compassion.

    Courage to speak out at a senior level, to understand the impact of the current cuts and changes and stand up for nursing will be critical. But, the responsibility for enabling this to happen doesn't just sit with our leadership, it sits with everyone. It is easier to have the courage to speak out when you feel you have the support of others around and below you.

    Compassion for each other, understanding the challenges we each face at the various levels we work at, including the compassion of our leadership for the front line and the compassion of the front line for those in leadership positions is key, that is what gives us courage.

    So let's stop the nurse bashing, whether it's senior leaders criticising the front line (or standing back and doing nothing when others are doing this) or whether it's the front line attacking our nursing leadership, they are equally destructive and will conspire to ensure we fail in delivering something that after all, is why we all came in to nursing, the values that are the 6Cs.

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  • 6c's

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  • 6c's article for trigger 1. uni work

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