The Francis report into appalling standards of care in Mid Staffordshire calls nursing to reflect on history
The Francis report into appalling standards of care in Mid Staffordshire calls nursing to reflect on history. From 1860-1970 standards of patient care were the responsibility of the ward sister (or charge nurse). A powerful figure, she taught, organised and supervised all those working on her ward. Her authority came from her position as trustee and transmitter of an ethos: vocational, altruistic, practical service to patients.
This ethos was internalised in the culture of the ward and the NHS ward prayers were held regularly until the 1960s. Essential care for patients as an altruistic service corresponds to Klein’s (1995) model of the NHS as a “secular church”. Indeed, the terms “sister” and “service”, with their religious connotations, were fundamental.
During the 1960s, management theorists, educationists, sociologists and psychologists criticised the vocational model as demeaning, paternalistic and oppressive. Over the following decades, market-driven consumerist models from outside nursing, and a move to education inside it, affected values of care. The ward sister lost her role in training and her focus on patients. Vocation was replaced by utilitarian self-interest. Although the title “ward sister” remains, as has the term “service”, the nature of the role, and the meaning of the words have changed. The secular church model has become what Klein calls a garage model. This is a market-driven model, led by business managers who view the patient as the customer. It is the model of the supermarket and fast-food outlets.
The secular church model arose from the values of a specific historical culture. Despite the prime minister’s call for a revival of vocation, is it realistic to expect staff to be motivated by values of vocation and self-effacing service? Culture has changed, and those values are not so acceptable in a modern multicultural society.
Should we accept the garage model best fits diverse cultures, needs and finances of 21st-century Britain? Perhaps hospitals should resemble businesses, such as McDonald’s, and require similar leadership, management and quality controls? In this garage model the ward sister is the shop manager meeting tick-box targets, the nurse the team leader and the healthcare assistant the McDonald’s crew member.
But are patients more than just quality-controlled consumers? Are practical virtues, such as kindness and compassion, vital to ensure patients’ fundamental needs are attended to - as the Department of Health’s (2012) recent nursing vision recognises? As nursing history teaches, these values are not a technique. They are an inner attitude. Cultivating practical virtue in UK nursing requires re-orientating leadership, policy and training to a primary focus on the basic practicalities of direct care. But it also needs a revival of the vocational, secular church model, inducting staff into virtue, as the ward sister once did.
Ann Bradshaw is senior lecturer in adult nursing, Oxford Brookes University.
- Click here for a print-friendly PDF of this article