Ethics,care and the workforce ‘crisis’

I write this as we prepare for the 24th International Nursing Ethics conference, hosted this year by Brunel University London on 30th and 31st August, on the theme of Ethics, Care and the Workforce ‘Crisis’. ¹ The conference provides opportunities to engage with questions such as: What characterises the alleged care workforce ‘crisis’? Who counts as a member of the ‘care workforce’? Which policies are most likely to safeguard care into the future? How should health and social care practitioners, educators, researchers and leaders respond most effectively? And why do we need an urgent reconsideration of philosophies which underpin ethical approaches to care appropriate for our times?

First, what characterises the alleged care workforce ‘crisis’? Our media are currently awash with news and opinion pieces regarding ‘crisis’, pertaining to global conflicts, the climate emergency, higher education ² and to health and social care services. ³ In the United Kingdom (UK), the latter ‘crisis’ is often characterised in relation to challenges recruiting and retaining health and social care professionals. A response was proposed in the form of the NHS Long-Term Plan. ⁴ Crisis in care is, however, not new.

Writing in 1994, three decades ago, Susan Phillips and Patricia Benner introduced the topic as follows:

There is a crisis in caring for persons that cuts across the boundaries of the helping professions. Patients feel depersonalised and processed, students suffer from inadequate attention[…] Caregivers are rewarded for efficiency, technical skill, and measurable results, while their concern, attentiveness, and human engagement go unnoticed within their professional organisations and institutions […] personhood and caring have been eclipsed by the depersonalising procedure of justice distribution, technological problem-solving, and the techniques and relations of the marketplace (5 p.1-2).

This historical portrayal is likely to resonate with readers. Readers committed to excellence in care. Readers who struggle to respond creatively to current challenges of short staffing and waning morale. Readers who are now confronted with new challenges and opportunities such as developments in Artificial Intelligance. But do current challenges represent a ‘crisis’?

Janet Roitman ⁶ describes ‘crisis’ as ‘omnipresent’, ‘as an object of knowledge’, with ‘crisis texts … a veritable industry’, as ‘judgement’ and as a ‘cognate’ of ‘critique’. She goes on:

Crisis-claims evoke a moral demand for a difference between the past and the future […] a moral task of an ethical demand, being based on a perceived discrepancy between nature and reason, technical developments and moral positioning, knowledge and human interest […] The world is as it is, but it could be otherwise (6 p.8-9).

Roitman invites readers to ‘put less faith in crisis […] asking what is at stake with crisis in-and-of-itself’ (6 p.13). We can look forward to such perspectives being interrogated at our August conference.

Second, ‘who counts as a member of the “care workforce”?’ Documents such as the NHS Long-Term Plan ⁴ focus on the formal/paid care workforce, for example, registered professionals in employment. However, much care is delivered by families and friends who receive little attention, reward or gratitude for the often 24/7 contribution they make. These are contributions which save governments significant resources and which complement, and often replace, the work of the paid care workforce. Policy approaches to supporting both formal and informal care workforce have never been more pressing as our ageing population grows, fertility rates fall and multi-morbidities escalate.

Third, which policies are most likely to safeguard care into the future? Electioneering is currently in full swing in countries such as the United Kingdom (UK) and United States of America (USA). Voters in such countries should commit to better understand what is being promised by politicians and what can be delivered to respond to current health and social care challenges. They will need to balance a number of potentially competing priorities and, critically, to reflect on self-regarding and other-regarding interests. A recent issue that had a high media profile in the UK related to an accusation that a particular political party planned to raise taxes. The accusation was rebuffed by the party in question, perhaps to quell voters’ anxiety, and win favour with those in higher income brackets.

Given increasing health and social care need, and escalating cost, should it not be the case that parties should promise tax rises as a badge of honour? As a commitment to the provision of life-enhancing goods, such as health and social care services and higher education? Instead, it appears to be the case that some political parties are in the business of moral backsliding and values’ erosion, instead of demonstrating moral resilience, courage and ethical leadership. Again points that will, most likely be debated at our August conference.

This leads to a fourth question: ‘how should health and social care practitioners, educators, researchers and leaders respond most effectively?’ Just recently the Chief Executive and General Secretary of the UK Royal College of Nursing, Pat Cullen, stepped down from her position to run as a political candidate in Northern Ireland. ⁷ She said ‘now is the right time for me to step forward into the political arena to champion the issues and opportunities for the community I love and this is what I am fully determined to do […] adding that this was an opportunity to support better funding for public services’. Few nurses will have the courage or confidence to step forward in this way, however, this does not mean we lack power or impact. We have the opportunity to vote and, through role modelling, education and research, we lead and influence others.

Finally, how and why do we need to urgently reconsider philosophies which underpin ethical approaches to care? Our current repertoire of ethical theories and approaches remain predominantly Western in orientation. It is, therefore, timely and critical to engage with philosophical and ethical perspectives that provide new lenses with which to view ‘crisis’ and care workforce challenges. It is hoped that we will confer productively, critically and respectfully when we meet in London in August to arrive at new understandings and creative solutions. I look forward to seeing you there.