Fab article Mark. Our work at HSMC (Sawbridge and Hewison 2011. Time to Care?) also considers how we need to create a system which looks to support nurses and recharge their emotional bank account -which is often overdrawn. We are working with 3 hospitals to test the feasibility of introducing a model of support, and will share our findings when we have some! This is an important dialogue to illustrate the complexities of caring and help us all to find ways to get it right for patients and, as you say, for individual nurses, most of whom want to do a good job.
At the University of Birmingham we recently convened a Think Tank to look at issues affecting the delivery of compassionate nursing care. We have produced a policy paper with the findings called "Time to care?" which can be accessed at www.hsmc.bham.ac.uk. The key issues in our paper are as follows:
• In the 1950’s Menzies identified that nurses’ deal with situations such as death and dying, on a daily basis whilst most lay people may not experience this in a lifetime. This remains the case with nursing today. In order to avoid them being overwhelmed by anxiety they need ways of coping and these mechanisms need to include systematic support for this emotional aspect of their work. It is rare to find such a system in the day to day realities of ward nursing. In addition, the recognition of nursing as a series of tasks that are “frightening, disgusting and distatsteful” (Menzies 1960) is rarely discussed, and therefore not recognised by organisations or responded to. Coping mechanisms may have been eroded over time because they were not fully understood-for example task based nursing has been replaced by personalised care. Whilst the authors do not argue for a return to this approach, they do highlight the need to recognise the impact of this change and to take appropriate action. For example the Samaritans employ a model of emotional support for their volunteers which ensures they are able to cope in their role of providing care to others at their time of need.
• Caring is seen as an easy task - kindly next door neighbours are described as caring for example, and therefore if it is simple why do nurses not just do it? This rationale then leads to the uni-dimensional approach of blaming the individual nurse and/ or their education - the “too posh to wash” syndrome. This approach belies the complexity of what it means to be a registered nurse in today’s complex healthcare environment, and also ignores the reality of caring which is recognised in other areas of national policy- such as the National Carer’s Strategy . It appears that this recognition of what it means to be human is forgotten once nurses are in paid employment.
• Ward and board nurse leadership is recognised throughout the literature as crucially important in setting the right standards for practice and delivery of good, compassionate patient care. The energy required to create a culture of caring and develop, support and inspire the nursing profession does not appear to have been articulated in ways which Boards can understand or relate to. Most Ward Sisters/Charge Nurses and Nursing Directors have a myriad of other responsibilities which take their time away from nursing (Burdett 2006; RCN 2009). In addition Newchurch (1995) identified that 75 per cent of nurse directors did not have line management responsibility for nurses which creates an added dimension when trying to influence practice and standards.
• Finally, the paper identifies a sense of dissonance between being a” good” nurse and a “good” employee. A “good nurse” might be expected to know who were the illest patients on their ward, how many needed help with eating, or the number of patients with pressure ulcers. However the mangers may want them to know how many patients are in A&E waiting for a bed, and how many beds they will have on their ward to accommodate this need. Whilst these are not mutually exclusive requirements, it serves to illustrate the tension between system pressures and priorities, and nursing care. For nurses struggling to identify how to measure the components of compassionate care in a way which are widely accepted and can be bench marked, the management culture can distort priorities and the personalisation of care can be overlooked as the needs of the organisation, in terms of achieving high profile performance measures, takes precedence. This can create internal conflict between being a “good nurse” and responding to what is important to individual patients, and being a “good employee” and responding to what is important to the organisation/their managers. The nurses’ Code of Conduct states “make the care of people your first concern, treating them as individuals and respecting their dignity” (NMC 2008), which further compounds nurses' sense of conflict.
In summary, whilst we agree with the Prime Minsiter's view that hourly rounds can play their part, (referred to as "Intentional Rounding" in our paper), mechanistic tasks on their own do not contribute to the delivery of compassionate care - merely compliance.
We hope our paper will contribute something new to the debate, and lead to the establishment of support mechanisms for nurses to help them to deliver compassionate care consistently. That is the reason most nurses joined the profession.