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The big issues in nursing

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Nursing seems to be facing more changes and challenges than ever before. Earlier this year, Nursing Times held its annual summit at which the key issues affecting the profession were debated. Steve Ford reports on a special round-table meeting, held in April, to update this discussion

In the wake of cases such as that of Mid Staffordshire NHS Foundation Trust, there is now an onus on every nurse to be a role model for other nurses if the profession is to avoid criticism.

The fact that not all nurses want to be leaders but all are role models was one of the key messages to come out of a special round-table discussion between leading nurse stakeholders, held in April by Nursing Times.

The event acted as a forum on topics such as the Prime Minister’s Commission on the Future of Nursing and Midwifery, the NHS Next Stage Review and the Productive Ward series, as well as nurse leadership and nurse-led models of care.

The development of nurse leadership has been mentioned in both the Next Stage Review and the PM’s Commission. But Rosemary Cook, director of the Queen’s Nursing Institute, said she thought more nurses aspired to being a good role model for other nurses rather than being a leader, adding that it was essential that all nurses did set a good example.

‘There is that onus on every single nurse, because if one person ignores call bells or something, that gives “permission” to everyone else to ignore a call bell. So everybody has to be a role model,’ she said.

She added that what she often found most upsetting about examples of poor care was that the cause was often purely down to the behaviour of staff.

‘It’s too easy, a lot of the time, to blame policy, the ward environment, the fact that the trust is short of funds or whatever it is – that doesn’t mean you can have a conversation over the patient, that doesn’t mean you can walk by a dirty commode without doing anything about it,’ she said.

Pippa Gough, a nurse and assistant director of clinical quality at the Health Foundation, said that feedback and communication between colleagues – both nursing and medical – was key to acting as a good role model. For example, if a colleague began talking over a patient, you should not only discontinue the conversation but take them aside afterwards and explain why you had done so.

‘That sort of minute by minute, small, timely feedback is really important in terms of developing role modelling,’ said Ms Gough. ‘If everyone is able to give that very clear feedback, everyone – doesn’t matter if you are doctors, nurses or a multi-disciplinary team – is going to start behaving differently.’

Ms Cook added that to some degree being a role model was initially about acting the part. ‘You kind of pretend to be a nurse who knows what they are doing and eventually you grow into it,’ she said.

Ironically, there was also suggestion that the much-maligned Nightingale wards may have actually helped with role modelling and patient dignity.

Ms Cook said: ‘When you had Nightingale wards all the patients were watching – it discouraged ignoring one patient, being rude to a patient, being impatient with a patient because everyone else was watching you.’

Ms Gough agreed that, while modern wards and rooms provided more privacy, Nightingale wards had acted as ‘containers’ of both patient and nurse anxiety because nurses were visible and present all the time.

‘Patients could see that but also nurses could see one another and that things were in control,’ she said.

Ms Cook acknowledged that acting as a good role model in the modern NHS was not always an easy task. ‘The pressures that are on nurses in the working environment will make them more or less easily able to do this role modelling. And, yes, it does get damned difficult. I think it is much harder than it ever was when I was working on the wards.’

Howard Catton, RCN head of policy, development and implementation, also noted how hard it was working under the pressures that frontline nurses often had to cope with. Most of the time, the right people with the right values were being recruited into nursing, he said, despite suggestions that some presumed tenets of nursing, such as compassion, had been watered down.

Referring to the introduction of compassion testing for nurse recruits at some trusts, as previously reported by Nursing Times in April, Mr Catton said: ‘By and large we do get the right people in with the right values and the right ambition, and wanting to do well and all the rest of it, but they get ground down by “compassion fatigue”.

‘Many nurses go so far above and beyond [what is expected] because of their levels of commitment,’ he said.

Speakers suggested that with the right support good role models, if they wanted to, could go on to become good nurse leaders as well. ‘Part of being a role model is imparting confidence, which is hugely important again for leadership,’ said Ms Gough.

One initiative that has also helped promote nursing leadership by giving nurses at ward level more control over their service environment has been the Releasing Time to Care: Productive Ward programme. Launched in January 2008 by the NHS Institute for Innovation and Improvement, the ‘Productive’ tools and techniques are now being expanded into a range of healthcare settings.

Kristy Parnell, an associate with the programme, noted that feedback had been very positive. Nurses who had worked with the programme described it, she said, as ‘the biggest thing that had ever happened in nursing’.

‘Actually having a programme focusing on nurses that isn’t top down, that hasn’t been a policy drive, has been a massive pull and continues to be in the other areas that Productive’s are moving into,’ she added.

‘There has been a huge amount of enthusiasm and a change for a lot of people in their feelings about going into work – the control they have over their environment, understanding how they are performing, having access to improvement tools and meaningful real time information which allows them to increase the quality of patient care.’

But, Ms Parnell warned, the institute was now working to avoid the threat posed by the recession by identifying ways to encourage those in control of NHS finances to continue to invest in the Productive series.

‘We are now at the stage where, against the economic climate as it is the moment, SHAs will inevitably start wanting more for less,’ she said. ‘How do we engage and ensure that organisations continue with the programme and do not see ‘Releasing Time to Care’ as a project that they invest in for a limited amount of time, but as a vehicle for long term quality improvement and cultural change?’

Productive Ward was held up by the prime minister as an example of why nurses should be given more control over care settings when he announced his Commission on the Future of Nursing and Midwifery in March.

The creation of the commission, which had its first full meeting last week, has been mostly welcomed but a number of concerns were raised about its structure and remit.

For example, Ms Gough said: ‘I think to set up a commission on nursing separate from any other profession is complete nonsense – you can’t view one section of the workforce in isolation.’

Additionally, she said the membership of the commission should have been drawn from a wider pool that went beyond nursing and midwifery. ‘We know what the view of the world is as nurses. How do we get some new views?’ she said.

Mr Catton said the commission had to recognised as a ‘huge political opportunity’ but said he wanted to see ‘bigger ambition’ from its remit – such as looking at how nursing would be affected by the wider NHS quality agenda and the current economic downturn.

In particular, Mr Catton said he was disappointed that commissioning was not in the original remit of the commission.

‘My worry about commissioning not being given a specific name check is that the spending of £70bn of NHS money will be decided through commissioning, and nurses aren’t seen to be there,’ he said.

Ms Cook also questioned another part of the commission’s remit, which deals with the development of nurse-led services – and in particular the increased use of the social enterprise model, which was also highlighted in the NHS Next Stage Review.

‘It will be a challenge to avoid focusing on the exciting end around innovation and entrepreneurial practice and forgetting the whole main body of nursing, which is delivering the care on a day-to-day basis,’ she said.

‘Are we recruiting people who want to go into nursing to be by the bedside and look after patients or actually recruiting people to manage services, to organise things and be accountable for care?’ she said.

She said there were several questions to be answered around nurse-led services. For example, there needed to be a distinction made in the importance between innovation within the NHS and more risky independent ventures such as social enterprise schemes.

‘There is a different area of excitement, entrepreneurship and innovation, which we need, that happens within the profession and under the umbrella of the NHS. A lot of people we can enthuse to do that,’ she said.

‘If we want some of them to step out of there, then that’s a smaller group and different questions altogether,’ she warned.

‘Although it’s the minority and not the majority that will end up working outside of the NHS, the vision that this government has for lots of nurse-led services and social enterprises, that’s where you will get “naked professionalism”,’ she said. ‘They are not surrounded necessarily by the sort of team you would get in a hospital or NHS service, so there’s nothing between them and being struck off but their own professionalism.’

Ms Gough questioned the use of the term ‘nurse-led’ itself. ‘The problem for me with nurse-led models of care is this thing about autonomy – are they truly nurse-led or who else do they need to get in on the act to enable nurses to make decisions?’

Ms Cook agreed. ‘You could argue that autonomous practice is the emperor’s new clothes of nursing. Does it really exist? How autonomous are these people?’ she asked.

Ms Gough added: ‘The “real politic” is that not many nurses have total decision-making power in terms of the way care is organised – the reality is you need to be able to negotiate really skilfully and influence really skilfully to push through the ideas that you think are important and place those in the context of other people’s ideas.’

However, Ms Cook disagreed on this point. ‘I think nurses know that and do that – nurse-led practices are a good example,’ she said. ‘They employ the GPs, they employ other people. There is real pragmatism about that. I think the danger is when nurse-led is used as a slap in the face for doctors, and sometimes that is what it’s about. All this promotion that nurses can do everything is basically unhelpful.’

No doubt many of the issues discussed at the round-table will still be on the agenda at the next Nursing Times summit – as well as some new ones. The NHS may be facing the prospect of a new Conservative government, for example. 

But, as Ms Cook said, perhaps what the profession needs most is a period of political stability to enable it to develop from within.

‘From an organisational point of view, we’ve had endless change and people are fed up of that sort of change,’ she said. ‘But we should be having endless, endless, endless change from within nursing focused on the patients.’


The Nursing Times Summit, held on 15-16 January 2009 in Chalfont and Latimer, was sponsored by the RCN, the Health Foundation, NHS Professionals, the NHS Institute for Innovation and Improvement, and ConvaTec UK.
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