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Mixed messages on CPR give nurses an impossible dilemma


The two stories above report on incidents in adult social care and prison nursing respectively. The headlines stand like bookends marking 18 months of nursing under particularly challenging conditions.

In the first case an experienced nurse received a 24-month caution from the Nursing and Midwifery Council after failing to give cardiopulmonary resuscitation (CPR) to a care home resident who was not breathing, had no pulse or vital signs of life and “was almost cold” when the nurse arrived on the scene.

In the second case two nurses carried out CPR on a prison inmate who had hanged himself, despite “obvious signs of death”. Both nurses believed they were required to attempt CPR – no matter what the circumstances – until death had been officially confirmed.

Joint guidance on CPR has been issued by the Royal College of Nursing, the British Medical Association and the Resuscitation Council (UK). However, the 37-page document focuses on decision-making while patients are alive, and covers issues such as advance directives, patient capacity and discussions with relatives. As far as I could see, the closest it comes to addressing the situation these three nurses faced is a single sentence: “In all situations, where CPR will not work it should not be offered”.

So why did one nurse receive a caution for failing to follow a specific line of action while two others were criticised for following that very line of action? As an online comment on the latter article puts it bluntly: “Damned if you do, damned if you don’t.”

Prison nursing and adult social care nursing are very different but both specialties demand unique levels of commitment and compassion from the people who choose to work in them. And both specialties are struggling.

In May we reported that nurses working in prisons were being harmed and put at risk by a surge in the use of the psychoactive drug known as spice.

Later that month we reported that prison nurses were “becoming demotivated, stressed and burnt out”. They reported working under “extreme pressure” within an environment where care requirements were not fully understood. RCN members warned that prison nurses were operating within a service in crisis.

Also in May a public accounts committee report on the state of the adult social care sector concluded it was in “a precarious state”. The committee said nurses in the care sector felt under-valued compared with those in health and called for a national recruitment campaign to tackle negative perceptions and showcase care nursing as an important and rewarding career.

Just last week the RCN warned that critical challenges facing the NHS would deepen without significant investment in adult social care. The college issued the warning after a new study predicted the number of adults aged 85-plus and older needing round-the-clock care would almost double to 446,000 in England over the next 20 years.

Nurses work in a profession where their practice is subject to constant scrutiny – as it should be. Nurses in prisons and adult social care work with this scrutiny, and they do so against respective backdrops in which behavioural issues and end-of-life concerns will predominate.

These nurses deserve support and the same level of compassion we expect from them in their daily practice. Contradictory judgements on their actions suggest systemic confusion and leave individual nurses bearing the burden of media attention and public anxiety.

We need nurses who have the commitment and skills to work in prisons. We need nurses who have the commitment and skills to work in adult social care. Nurses who want to work in these specialties deserve to be supported and valued. They also need to know exactly what is expected of them, particularly when they are working at the very boundary between life and death.


Readers' comments (3)

  • Probably one of the biggest dilemmas nurses have. Through all the discussion groups I have held when working at Local Care Force Training, this was the most contentious. We spent time sharing experiences and exploring the morals of these situations. More training on the differences of somatic death and molecular death and Preactive phases of dying would help all staff in their decision making process.
    In my opinion.

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  • This isn't to do with CPR. Neither of the decision making processes in these cases seem flawed yet the NMC is all over them like a rash. The bottom line is that nurses and their clinical judgement aren't trusted by the NMC or senior management. As a profession we like to undermine our colleagues and their judgement, and I think that is what really need to change.

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  • In the 1st case an experienced nurse of 44 years (so experienced she was trusted to take charge of the Home where she worked in the absence of the manager) believed she was acting in the best interests of a dead resident by not carrying out CPR. She was "thrown under the bus by her manager, reported to and hauled before the NMC who humiliated her, demanded she express contrition in writing for her actions and handed down a 24 month caution.

    In the 2nd case the staff would've been well aware of the NMC's treatment of Ms Kendall. Their actions can be fully understood.

    Unless of course the NMC chooses to disagree.

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