‘Invisible’ nurses have to find their voice

Looking at the poor state of English healthcare shows what happens when standards are lowered, writes Linda Shields.

The Weekend Australian of November 5 had a 22-page supplement entitled “Health of the Nation”. An exploration of Australia’s health system, its effectiveness, costs, economics, accessibility and equity for the population, was based on a survey about ease of finding a general practitioner, dentist, costs borne by the patients, dental and mental health services and others.

It included an “expert panel” of doctors, a health economist, an epidemiologist and a consumer representative. Despite the fact that 55 per cent of Australia’s health workforce consists of nurses they were completely ignored, with the word “nurse” occurring only three times in the whole 22 pages. I have asked the editor of the supplement to comment, but to date no explanation has been forthcoming.

Despite remaining largely unheeded by the Weekend Australian, we have one of the highest standards of nursing care in the world. In the financial crisis-racked UK, things are much worse.

While working there four years ago, I was constantly amazed at how far behind nursing in England was (this does not pertain to Scotland or Wales). After all, the home of Florence Nightingale was, for a long time, at the forefront of the development of nursing as a profession.

In 2008, in England, less than 10 per cent of nurses had a degree, students needed only the equivalent of grade 10 passes to enter university courses (and it was a pass only – high marks were not sought), all funding for nursing education came from the National Health Service (NHS), rather than the higher education funding authorities, senior nurses still took the title “sister” and the matrons had been brought back.

One of the strangest things I found while living in England was that all students were entitled to a substantial, living-wage bursary, but those studying the diploma program received over double the amount paid to students who were reading for a degree. A few universities fought this. Birmingham and Manchester universities (amongst a small handful) had degree programs of the highest standard and which admitted only the highest achieving school leavers.

However, most universities were more than happy to provide the NHS with pairs of hands to staff the wards, and thereby benefit from the substantial amounts the NHS paid for nursing education.

Change of government in the UK and the economic downturn brought changes, but none good for nursing. David Cameron, the Conservative Prime Minister, was always against degree education for nurses. Recent moves to see nursing education purchased from universities by consortia of mainly medical doctors and a few other health disciplines, set up as replacements for the strategic health authorities, will remove any chance of nursing education being anything but controlled by these consortia. I contend that the declaration of the Nursing and Midwifery Council (NMC) for all nursing registration to be at degree level by 2013 (Royal College of Nursing 2009) must be under severe threat.

If all this is happening in the UK, could it happen in Australia? Is our wonderful high standard of nursing education, practice and research under threat? If we remain complacent and do not be proactive with politicians and the media, we could lose much.

While we complain about nursing’s invisibility, few of us ever actively engage with the media. Many are too scared to do so, fearing punishment by their employers, and rely on their industrial and professional associations to speak up for them. While these bodies do a great job advocating on behalf of their members, individual nurses, at least those who work for the government agencies, find it difficult to be more vocal. This is probably true of most professions employed by government.

Certainly, the medical associations are vociferous over issues that they perceive affect their profession, but few individual doctors speak out. However it is usually doctors and not nurses whose opinions are sought by both the media and politicians. But why should we sit back and accept that? We could be proactive by using our colleges and associations, professional bodies and unions more readily to contact relevant politicians and media, give opinions and voice concerns.

Can we fight harder? While I do not necessarily perceive Florence Nightingale as the one who “started” nursing (the PR machine that surrounded her promoted her “caring” at the expense of her huge talents in statistics and epidemiology, and there were many who went before her who did as good a job as she did, but who have been ignored). We can look to her and to other great fighters for nursing, such as Catherine McAuley and Lucy Osburn, and ask “would they have kept quiet?”

Of course not.

Victorian nurses are considering strike action because of a proposal to cut the state nursing budget by $100 million and Tasmanian nurses are worried by proposed job losses. The Victorian government states that nurses will be replaced by healthcare assistants, something that is happening across the UK. Roger Watson and I have been warning against blindly following the UK since 2007, and have written about the cultural cringe that sees Australians thinking that what they have is nowhere near as good as other countries. This is only too apparent in the argument that health care assistants can replace nurses – if it works in the UK, then it should work in Australia.

I argue that little about how nursing is run in the UK will work here. If is not working there, why should it work in Australia? Over the last ten years, there have been scandals about poor nursing care reported at least weekly in the British press, and many patients have died. While the media has been vociferous in damning the state of nursing, they consistently miss the point and blame nursing education being moved to universities.

Surely, and this is supported by very good evidence from Linda Aiken and her team, it is nursing education in the UK which is to blame, but not because it has been moved to universities, rather, because it is of such a low standard. There have been reports of nursing students who are innumerate and illiterate (how does one do drug calculations or document nursing care?), and there has been a real blurring of roles between registered nurses and healthcare assistants, so it is just about impossible to know which one is doing the nursing care. Indicative of the problem of the effect of these low standards of education is the fact that the scandals are mostly happening in England, not in Scotland or Wales, where all nurses have degrees.

This month, after all the scandals about poor nursing care in England, Nursing Standard and the Patients Association held an emergency summit to discuss the causes of poor care and to try to find solutions. While I have not been able to find a full text of the proceedings, nor the composition of the panels, it was chaired by Patients Association vice-president, general practitioner and broadcaster Dr Phil Hammond. Some results have been published, which include 10 points for action:

1) Ensure all healthcare organisations make patient care their core focus.
2) Recognise inadequate staffing levels as an indicator of poor care.
3) Enhance support for ward managers and community leaders.
4) Reduce bureaucracy and paperwork burden; for example, simplify the system for managing poor practice.
5) Foster the understanding that good nursing makes good economic sense; need to regulate HCAs.
6) Build resilience in nurses to prevent them burning out.
7) Whistleblowing should be re-named ‘‘speaking up’’ and should become a professional expectation.
8) Improve nurse training: encourage a better correlation of theory to practice.
9) Set explicit standards and expectations for nurses’ behaviour and care provision.
10) Promote and enhance support for nurse leadership centrally and locally to create good role models.

In addition, a “Care Campaign” was launched to “fight for improvement in patient care across the UK”. They devised “CARE Challenge” which “covers four fundamentals of care that are the main factors in complaints to the Patients Association helpline.

C - Communicate with compassion
A – Assist with toileting, promptly to ensure dignity
R – Relieve pain effectively
E – Encourage adequate nutrition and hydration”

My reaction to this is one of dismay. Surely all these things are an inherent part of nursing care?

Some of the 10 points sounds good, but many are punitive. Again, we see “nurse training”, rather than “nursing education”.

Unless nurses themselves take ownership of their educational content, realise it has moved into the 21st century and that terms like “sister” and “matron” are archaic and, as feminine terms, do not fit the men who are nurses, nothing will improve. It is horrific that assisting with toileting and with pain relief are obviously such a cause for concern that a public campaign is being run around them.

Nursing in England is definitely going backwards, and I do not believe that these campaigns will do much when the main fault must be laid at the door of the way nursing is taught. If nursing remains at diploma level, if the entry standards continue to remain low, if the almost total absence of critical thinking and enquiry remains, and if the NMC’s push for a degree educated workforce is not implemented, then nothing will change.

Australia, with its ongoing cultural cringe will continue to look to Britain. Politicians, eager to save money, will do exactly what Victoria is planning now, employing uneducated healthcare assistants to do nursing work. Australia could see the same sort of downturn in standards of nursing care, with unsafe practices and consequent deaths if we blindly follow the UK. Australia has a terrific healthcare system; wonderful nursing, and its education. Let’s celebrate it by using our democratic processes to tell politicians and the media all the great things nurses are doing, and lobbying journalists, such as those who wrote the “Health of the Nation” supplement in the Weekend Australian, about what fantastic nursing care, systems and nurses we have in Australia.

Linda Shields is a professor of paediatric and child health nursing from Curtin University. A fully referenced version of this article is available upon request.

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