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Editorial: The future of clinical nursing: meeting the needs of patients for compassionate and skilled nurses?

2011; Wiley; Volume: 20; Issue: 13-14 Linguagem: Inglês

10.1111/j.1365-2702.2010.03309.x

1365-2702

Ann Bradshaw,

Interprofessional Education and Collaboration

In 2009, the UK Prime Minister, Gordon Brown, established a Commission to consider the future of nursing and midwifery. One of its aims was to ‘help fulfil the public’s desire for compassionate, skilled care’ (Prime Minister’s Commission 2009). The Commission was established at the same time as the Healthcare Commission (2009) raised questions about hospital trusts in England. These questions related to the quality of nursing care regarding hygiene, provision of medication, nutrition and hydration, use of equipment, and compassion, empathy and communication. During this period, the Patients Association (2009) reported patient experiences of deficiencies in basic nursing care. The need for compassion in nursing had also been admitted by the Secretary of State for Health a year earlier (Johnson 2008). Similarly, the Welsh Assembly Government nursing officer stated that some of the most common complaints were about a lack of compassion (Santry 2010). In establishing the Commission, the Prime Minister made compassion, competence and the role of the ward sister, charge nurse or community team leader central. The term ‘compassionate care’ is reiterated and is the overarching theme in the report published in March 2010. But neither in its review nor in its recommendations did the Commission explain why it made these aspects central, or acknowledge problems identified by the Healthcare Commission, the Government and the Patients Association. The Royal College of Nursing (RCN) also failed to acknowledge shortcomings in the basics of care. It responded to the Patients Association report defensively by suggesting that examples in the report ‘should not be allowed to overshadow the vast majority of good quality healthcare…’ (Evans 2009, p. 5). The Prime Minister’s Commission report (2010, p. 2–9) recommended a central place for nursing, protection of titles, regulation of roles, improved status, pledges for quality and compassionate competent care. Notwithstanding the report’s lack of detail, with regard to evidence base, analysis and methods, it lamented what it said was the public misunderstanding of nursing, suggesting that the media for 25 years had been and still were responsible for belittling and stereotyping nurses. The Commission chair, a former nurse, reinforced this view in her letter to the Prime Minister at the opening of the report by commending the fundamental change to nursing brought in by the Briggs Report of 1972, which had led to a new nursing system, its nurse preparation, authority structures and values. Two apparent paradoxes emerge. First, UK nursing has achieved status by embracing new ‘maxi roles’, blurring boundaries between cure and care (Godlee 2005). However, this seems to have led to the paradox that the basic practices of nursing care are often found wanting. The second paradox concerns the past. It is arguable that, by emphasising compassion, competence and leadership the Prime Minister’s Commission is harking back to the system of nursing replaced 25 years ago, which it disowns but which it recognises to be still in the public memory. In a further irony, a health services researcher (Black 2005) also points to nursing history by suggesting that the current loss of public faith in the UK hospital system could be restored by nursing as had happened in the 19th century. It is arguable, therefore, that an historical analysis of this system of nursing may cast light on the paradoxes and offer a vision for the future of nursing. Fundamental to the previous nursing system was the ethos that underpinned learning to care. By the end of the 19th century, nursing had reformed the hospital system. The new nurse was educated and from a high social class, yet she was prepared willingly to perform the most menial of work (Bradshaw 2001a). For example, in 1880, a senior physician at the Westminster Hospital (Sturges 1880, p. 40) wrote with admiration of the absolute dedication these nurses required: ...of the ingratitude of many patients, the actual violence of some; of the careful tending of those who have reached the very bottom of social degradation... All this the hospital nurse endures week after week, with small money remuneration, limited prospect of promotion, scanty share in any credit which may accrue, and prompted only by a motive which, however it may find expression, is of the highest and noblest kind. The dignity of such service seems to me quite unequalled. Bonham Carter, Secretary to the Nightingale Fund, described Nightingale’s beliefs about what counted as good nursing: order, obedience, behaviour and general conduct were essential for the proper working of the hospital system. The matron was responsible for the efficiency of the nurses; but she was responsible to the medical officers that their orders for the treatment of the sick were carried out. This necessitated a partnership between the matron and doctors (Bonham Carter 1880). Two articles from an anonymous doctor and nurse supported this view (Anon 1880a,b). The writers may have been the surgeon, Joseph Bell, and the St Thomas’s trained nurse, pupil and protégé of Nightingale, Angélique Pringle (Baly 1986, p. 196). The good nurse was clever, dutiful, cheerful and kind, and needed to preserve ‘a clear, steady glow of inward brightness’, argued the nursing author. Plenty of clever, educated women offered themselves as nurses, as well as plenty of weak but kindly women, but not many had all the qualities needed to make a good nurse. The system was practical and thorough and had international relevance. This was commented on in a book first published in 1905. The book’s French author had argued that the English nursing system was superior to the French nursing system and was popular among the middle and upper classes because of the thoroughness of training and the discipline of nursing institutions and hospitals. He emphasised the thoroughness of training: ‘C’est en forgeant, qu’on devient forgeron’. Nurses did not need elaborate theories but did need practical skills which could not be learned from books (Anon 2005, p. 359). By 1932, the Lancet Commission (1932, p. 12, 61) made clear that doctors, matrons and ward sisters were deeply involved with, and committed to, the apprenticeship training. In many hospitals, a sister tutor or matron gave all lectures in preparation for the preliminary state examination, while honorary medical staff lectured second and third year probationer nurses without fee. Nursing shortages meant obsession with getting the work done, so that junior staff were not getting teaching in the individual care of patients, and senior nurses sacrificed their own leisure. Notwithstanding these pressures, it had remained ‘an axiom in the nursing profession that the patient comes first....’ In 1950, the Matron of the London Hospital (Alexander 1950, p. 307) wrote about the importance of maintaining existing standards of nursing care to make a patient comfortable and the doctor’s treatment and orders acceptable to him or her. ‘The principles of nursing care have to be learned while actually doing all the day to day and hour to hour duties for the patient. They cannot be learned in the classroom, although a sound theoretical knowledge is essential.’ Roy Calne (1971, p. 45), the surgeon, wrote that key to the traditional nursing system was the authority and responsibility of the ward sister role, which accorded her status equivalent to the medical consultant. ‘It was her ward, she always accompanied the doctors on their rounds, and, knowing the patients intimately, she was able to contribute to their medical care in discussion with the doctors and to the social welfare of the patient in discussion with his relatives.’ In 1976, a British Medical Journal editorial (Anon 1976, p. 1238) expressed concern with the Briggs proposals to change nurse preparation, fearful that acquisition of certificates would become an end in itself so that nurses would give little service ‘though highly trained in a series of particular competencies’. The editorial argued that a better clinical nurse did not evolve by passing more examinations. ‘By any standards that is not what nursing is about’. As the editorial concluded, in the future, ‘nurses must foster a caring attitude for all types of patients, and devote themselves particularly to the increasing problem of the elderly and chronic sick, while continuing to seek to improve their standard of technical ability backed by theoretical knowledge.’ Modern historians of nursing tend to interpret this former conception of nursing as oppressive subservience hindering the quest for status (Bradshaw 2010a). This is reflected in nursing histories from the 1960s which have considered the values of dedicated service to be outdated and incomprehensible (for example: Abel-Smith 1960, Baly 1973, Davies 1980, Maggs 1983, Rafferty 1996). According to Moore (1988), an historian who is critical of these kinds of approaches, assumptions about class and religion have tended to blinker contemporary historians, whose investigative premises tend to be egalitarian and secular. Without doubt, the system founded by Nightingale had its failures, as noted in Briggs and in the Prime Minister’s Commission. However, it is at least arguable that a reappraisal of this system may illuminate contemporary challenges in nursing. Three key principles emerge from the historical analysis which can be related to the modern nursing situation: the character of the nurse, competence in knowledge and skill and ward leadership. First, the guiding principle of the Nightingale system was the character of the nurse. Care as a practice depended on the cultivation of the virtue of compassion in the carer (Bradshaw 2009). From this perspective, compassion is suffering together with another as more than an emotion or feeling but as a precursor to practical help. The good of the patient and not any personal pleasure or profit-seeking was the sole motive. This was the inspiration for nurses to care willingly and wholeheartedly for the most basic and apparently repellant of human needs, the lack of which forms the concern of the Secretary of State for Health (Johnson 2008), Healthcare Commission (2009) and Patients Association (2009). The second principle is the preparation of the nurse for competence. Writers stressed that training involved the acquisition of skills and knowledge through daily practice. Intellect was necessary but not sufficient. The nurse training system from 1923 until 1977 was prescribed by the General Nursing Council (GNC) in a national mandatory syllabus. Student nurses were rigorously tested to an explicit standard set by the GNC in a state examination. This system was criticised in the Briggs Report and replaced a decade later by Project 2000. Nurse training became nurse education as it moved into higher education. Nursing students, rather than student nurses, were now supernumerary and no longer employed as part of the ward team. Yet, as explored in detail elsewhere, problems have been recognised in ensuring competency in practical skills because of the variability of nursing programmes, a consequence of the lack of prescriptive detail in curricula and assessment (Bradshaw 2001b, Bradshaw & Merriman 2008). The Nursing and Midwifery Council (NMC) draft proposals for pre-registration nursing preparation published in 2010 show that these problems remain. This is evident from nebulous statements such as: ‘Graduate nurses must have “presence” demonstrated through the energy and quality of their interaction,’ and ‘nurses must know the limitations and known hazards in the use of a range of technical nursing skills, activities, interventions, treatments, medical devices and equipment’ (NMC 2010, p. 42). The third principle is leadership. The ward sister role was fundamental to the hospital care of patients from the inception of modern nursing. She inducted nurses into the art and science of care. The doctor was the hospital director, the ward sister was the ‘captain of the team’ (Pearce 1949, p. 18–19). Official reports confirmed this (Ministry of Health 1947, Nuffield Provincial Hospitals Trust 1953). Professional changes which have moved nurse training out of the ward and given nurses individual accountability have removed the ward sister/charge nurse’s responsibility for training nurses. Organisational changes including the Salmon and Griffiths Reports of 1966 and 1983, individualised ‘named’ nursing policies of 1989 and 1991 and the NHS and Community Care Act of 1990 reduced the authority of the ward sister and charge nurse for the ward environment and ward services (Bradshaw 2010b). In 1992, the Audit Commission noted confusion in ward leadership. In 2001, the Department of Health (2001) admitted the need to strengthen the role of the ward sister/charge nurse. In 2010, the Prime Minister’s Commission (2010, p. 7) still recommended ‘strengthening the role of the ward sister’. The RCN (2009) as well as the Prime Minister’s Commission lamented the loss of the ward sister/charge nurse as clinical leader. The Prime Minister’s Commission, in line with the RCN and the NMC, considers the nursing profession to be key to the future of the UK National Health Service, yet fails to acknowledge current shortcomings in basic nursing care. Instead, it merely restates the requirement for compassion, competence and leadership, without addressing why they are lacking. A revised interpretation of history – albeit currently unfashionable – shows that these requirements formed a coherent interlocking system. Perhaps a reappraisal of nursing history could be a resource for a new vision of nursing that meets the needs of patients for compassionate and skilled care, which is relevant not only to the UK but to nursing internationally.