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Practice comment

'Counter the scapegoating and show the public you still care'


Hardly a day goes by without nurses being put in the line of fire for their lack of care and compassion. The release of the Francis report will inevitably intensify the focus

The first signs that nurses’ caring image was beginning to crack came over a decade ago when the new-style university education was accused of producing students who were “too clever to care”. This view is a far cry from Ann Oakley’s 1984 classic paper On the Importance of Being a Nurse, which showed how the qualities of the “good woman” were closely associated with those of the “good nurse”.

Oakley’s paper coincided with the start of my research to explore the relationship between student nurse learning and the quality of patient care. At the time, students undertook a three-year apprenticeship and the emotional style of ward management was key to the quality of learning and standards of care. A ward ran smoothly when “sister had rules and she let you know what they were”. Students also valued sisters “who went that extra mile” for patients and their relatives.

Revisiting my research in the 2000s, I found a very different educational system, an NHS that had undergone major changes and an older patient population with complex conditions. The NHS had become increasingly target driven, with rapid patient throughput, requiring nurses to be educated for new roles and tasks.

It is clear that nurses still care passionately about what they do, and systems should allow them to care both competently and compassionately. The ward sister - so key to the caring and learning environment of the 1980s - has all but disappeared.

Reflecting on the Mid Staffordshire Foundation Trust inquiry and the consequences of policy, it appears that nurses and nursing care have become the scapegoats and the lens through which difficult issues are viewed. This inquiry is a defining moment in the history of the NHS and reveals the pressure to meet targets and financial imperatives and how these affect the quality of care. The quality of nursing care came under intense scrutiny at Mid Staffs where, for a variety of reasons, nurses appeared to be unable to provide care that met patients’ physical and emotional needs. Staff, relatives and patients lived in an atmosphere where they were afraid to speak out about failures in care.

There are resonances here with the emotional labour analysis of my 1980s research, which showed high-quality care required both patients and staff to feel safe and cared for. The difference in the 21st century is that the effects of emotions on individuals, groups and organisations are more likely to be recognised and talked about, and nurses need critical, emotional and intellectual skills to care effectively.

The profession needs to brace itself to address and go beyond the Francis report and counter the scapegoating of nursing by drawing on the wisdom and experience of generations of nurses to show once again to the public how nurses still care.

Pam Smith is professorial fellow and head of nursing studies at the School of Health in Social Science, University of Edinburgh



Readers' comments (9)

  • Pam a nice article which I enjoyed reading. I have no doubt that much of what you say is valid but you fail to address the elephant in th room !

    The nursing profession has no leadership!

    Look at the latest scandel in Bristol -- A classic example of management failure resulting in alleged mortality/morbidity.

    Its the front line clinical nurses attempting to do their best in an impossible situation who become the target of relatives and the media.

    We have a CNO(Eng.) who refuses to acknowledge the devistating effect that the lack staff and inapproprate skill mix has on patient care. Instead of adressing the real problems of the profession she prefers to pretend that her rather idiotic 6C's will provide all the solutions ! --

    At a trust level we have "nurse" leaders who are complicit in reducing RN numbers. There is even one Trust who are saying that their "trained" care assistants will be counted as traine nurses !

    Until nursing finds and empowers leaders of caliber nothing will change. Clinical nurses and their patients will continue be the victims.

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  • I don't agree with Jenny Jones about the 6Cs being idiotic. If you read them in isolation, then of course I can see how they would be, but what's important is to read the full strategy and staffing (both levels and skill mix) is all there.

    However, I do agree that the real problem is in local senior nurse leadership and I'm not at all surprised at the horrific story of a trust that wants to include 'trained' HCA's in the number of trained nurses. Appaling!

    Sadly, there are many HCA's who do see themselves as trained. I suppose technically, they may well have had some training, but the difference is that this training is a million miles away from the training a registered nurse undertakes.

    Perhaps we should force organisations to publish not the number of trained nurses, but the number of registered nurses. But hang on, one of the recommendations is for HCA's to be registered, so that won't work either.

    Now I'm not against HCA's, they have always been a very valuable part of the team, but we have to find a better way of recognising this without undermining the hugely important role of the real registered nurses.

    When we have done this, then we can start to expose some of the dangerous staffing levels/skill mixes.

    I'll watch and wait......

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  • I was attracted to reading this article by the title of 'scapegoating' as in my opinion this is all too familiar. I particularly like the comments from Jenny ''Its the front line clinical nurses attempting to do their best in an impossible situation who become the target of relatives and the media''. In my experience this is very true, as a senior nurse for many years it deeply saddens me to see the nurses once again take the blame for poor standards. For many years now nurses have been crying 'help' as they cannot possilby cope with the ever increasing demands of fewer staff on the front line. In most cases 'the powers that be' seem to think the answer to the problems is to introduce document after document to record care given. In addition to this introduce specialist roles for every aspect or area of care one can imagine, often supported by a whole team of staff (nurses). When will someone realise that each additional document including the endless risk assessments mean more and more time away from the patient. On the 'front line' every minute sent writing often repetitively is a valuable minute of patient care lost. Further food for thought; if we took all of our 'specialist' nurses and placed them back on the 'front line' to increase staffing levels and expertise where it is needed, I believe the problems would very likely be resolved.
    Sue Share

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  • Sue Share | 13-Feb-2013 4:49 pm

    To suggest the removal of specialist nurses and advocating that they be sent back to the 'front line' to address the issue of poor staffing, shows the lack of aspiration that has landed nursing in nowhere land. I am a nurse specialist working in A&E. I am very much on the front line!

    Are we to get rid of Diabetic specialist nurses, oncology specialist nurses, cardiac specialist nurses, etc? (most often working alone and certainly without a "whole team of staff nurses") Are we so lacking in ambition for our patients wellbeing that we can't see beyond the bedside? Most patients don't live in beds or in hospitals. I know it's shocking, but it's true. What do you think happens to them when they are not in hospital? They have lives to live, families to support, careers. Someone has to help them manage their ongoing chronic problems to enable them to live the best life possible. Food for thought.

    I agree with you about endless, time-consuming paperwork, though.

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  • Pirate and Parrot

    Just to be clear about this - the Francis report does not lay most of the blame on nurses, and it tends towards blaming the higher echelons on management rather more.

    So pointing out what Francis has highlighted, is one approach to avoiding this scapegoating of nurses.

    Love, Parrot

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  • Jenny Jones

    I agree completely, the leaders just don't have insight into what their actions have caused. I strongly feel that bands 6 &7 ward managers had a choice to contest the proposals of staffing, targets, etc . . . . They knew what would happen after all staff nurses are not allowed to attend the meetings with management. Managers have this on their conscience and they should apologise to staff for letting them down. This could have been prevented . . . .band 6&7 managers had a choice to implement. If they had been more assertive and supported staff
    . . . The quality of patient care would be good.

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  • I am sure the CNO(Eng.) will be happy to find she has at least one "C" supporter !

    But will you point me to where I can find the powerful public statement(s) made by the "leader" which relate to staffing levels, skill mix, increased patient dependency Etc.,Etc.

    Until such time as I can read the headlines generated by the "leader" which relate to these topics I will continue to believe the profession has no leader and is in fact headed up by a Poodle who juggles with "C's" but in reality does not provide the support which front line clinical nurses so desperately need.

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  • I note with interest comments from 'anonymous' in response to my own views. I would like to point out that I too have worked as a Cardiac specialist nurse very much on the front line, also in nurse education and training, acute medicine, practice development and strangely enough currently practicing in re-ablement, therefore appreciate possibly more than most 'that patients don't live in hospital beds and have lives to live'. However it would seem that the impact of poor care provided whilst in hospital beds for some people unfortunately means that they no longer have 'lives to live' !
    As a specialist nurse practicing in A&E I understand fully that you are in the 'front line' as I suggested where I feel our specialist nurses should be! However having worked in many different areas I can assure you that many of our specialist nurses are tucked away in offices developing pathways, policies, procedures and audit tools, to name but a few. And yes of course each of the above mentioned are necessary but in my view not as necessary as 'quality patient care', in basic terms it matters not what is written on the documents if there are not enough nurses to deliver the care!
    I would never suggest that we were to 'get rid of' our specialist nurses (myself included), my 'food for thought' I admit was not explained well. My thoughts are; that the specialist nurses should work alongside the less experienced nurses on the wards in the acute sector as part of their role, sharing their specialist knowledge and experience, increasing staffing levels and giving the support where it is needed most. Surely if we don't get it right at this stage on-going care becomes 'no longer required' or more complex and often results in readmission?

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  • Nurses are easy to scapegoat.

    The NHS is really complicated and nobody actually understands it. Everybody has heard, seen and met nurses. So when something goes wrong, rather then explaining all about the trust and the management, its simpler and easier to attack the nurses.

    Nurses never defend themselves. The same people would never attack doctors or surgeons as doctors and surgeons would complain.

    Nurses are easy targets. The public do not know what a nurse actually does, how much pressure and how hard they work. So when a nurse doesn't smile or fit the national image or actually is human or tired they complain.

    Nurses are politically weak. Nurses never demonstrate in the streets, their unions never fight back against attacks. Nurses are not united. They never explain to the public what they actually do or how much under pressure they are.

    The 6Cs are a good idea but they need support. Its a bit like a sticking-plastic answer.

    Question: How do we make nurses more compassionate and more caring without spending any money?

    Answer: Create the 6cs. We can tell nurses this in a presentation and we can teach it to them in training. It is simple and it doesn't cost us any money. Obviously for it to work, we need to give them more support on the ward, more support in the hospital and more nurses which we can't afford because we are giving the PFI milions of pounds.

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