Abstract
Nursing is widely understood and understands itself as a care-giving occupation. It is through its relationships with patients that nursing is defined. Thus, when society becomes concerned about the care of its citizens, it is nurses who are held to account. Despite the multiplicity of sector-wide factors identified by Sir Robert Francis as contributing to the failures of care in England at Mid Staffordshire NHS Foundation Trust, it was nurses who were pilloried in the press, with the satirical magazine Private Eye running a regular feature entitled ‘Fallen Angels’. More striking than this widespread public and media offensive, however, was the profession’s inability to marshal a convincing response. Undoubtedly, poor nursing care is hard to defend and nobody could fail to be shocked by the picture that emerged from the Francis Inquiry. But the issue is more complex than this. The challenge that confronted nursing leaders in the face of widespread criticism following Mid Staffordshire was the growing gap between how the profession thinks about and describes its practice, and how nursing is perceived by the public and the reality of nursing work in contemporary health care systems.
Over the past 40 years, nursing has advanced its claim to expertise in terms of its care-giving role. Nursing’s contribution to society, or what the sociologist EC Hughes called the profession’s mandate, 1 has been expressed in terms of a distinctive bio-psycho-social model of care in which ‘basic’ and ‘technical’ tasks are integrated and primacy is afforded to the nurse–patient relationship. This is a quintessentially professional model of practice which hinges on a holistic understanding of the patient and the exercise of professional judgement in meeting their singular needs. But while nursing has been developing an occupational identity based on a professional logic with a deep understanding of individual patients at its centre, the challenges of an ageing population and the near universal drive for cost containment have increasingly pulled nurses away from this professed metier. Nurses today are expected to care for more acutely ill patients, many of whom are elderly, frail and have multiple morbidities that require coordinated input from a range of specialist practitioners. Pressure on resources has made it progressively more difficult to secure discharge from acute hospitals, and accelerated patient throughput means that activities that in the past could have been extended over a number of days are compressed into shorter time periods. 2 All of this has taken place against wider changes in the workforce that has seen an overall reduction in the number of qualified nurses, a concomitant increase in health care support workers and task delegation from junior doctors. Additionally, and in common with other professions, nurses’ work is subject to growing rationalization, standardization and external scrutiny through quality assessment and regulation. Perhaps unsurprisingly, research reveals that contemporary nursing practice bears only a fleeting resemblance to the profession’s holistic ideals. Nurses are not only increasingly distant from delivering direct care, with some estimates suggesting that health care support workers in England are now responsible for 60% of patient contact, 3 it is also the case that nurses undertake a wider range of activities such as managing information flows and integrating services. The latter activities contribute positively to the quality of patient care but are not captured by the prevailing professional image. 4
Professional mandates have an important role in making work publically visible, transmitting occupational culture and defining group membership. They are also important in encouraging members to strive for their principles when there is pressure to compromise.
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If the gap between professional ideals and reality becomes too wide, however, mandates can become dysfunctional
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and this can have a number of effects. First, it creates misplaced public expectations for practice, as a student nurse quoted in an independent review of nurse education in England makes clear:
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The public’s experience of the NHS is greatly influenced by their expectations. If they don’t understand that what nurses do has changed, how can we expect them to believe they have had an exceptional service?
Second, for nurses this mismatch between professional ideals and material reality can result in alienation from work, leading to burn-out, withdrawal from employment or diminished commitment reflected in indifferent standards of care.8,9 This was all too evident in the case of Mid Staffordshire, with accident and emergency department staff quoted as having become ‘immune to the sound of pain’.
Third, not only does such misalignment distort expectations for practice, it does not reflect what nurses actually do in practice, and thus prevents the profession from realizing its potential.
For some years, now there has been a growing body of critical policy commentary which has questioned whether the contemporary nursing mandate – with its exclusive focus on care-giving – can meet the requirements of modern health care systems8,9 and that the need for a reformulation has never been more apparent. In order for this to happen, however, we need to develop a better understanding of the substance of care work in the diverse contexts that exist in contemporary health care systems. At present, we are some distance from this aspiration.
In the aftermath of the events at Mid Staffordshire, a raft of initiatives intended to contribute to the contemporary crisis of care have been introduced in England.10–12 Collectively, these have focused on professional values, safe staffing, regulation, education and training. All are important but what is conspicuously absent is any systematic commitment to developing a better understanding of the niche occupied by the caring work force, the substance of this work, the knowledge and skills that underpin it and how this work might best be organized. Care work has distinctive features which restrict the possibilities for rationalization and constrain how health and social care be organized. Getting to grips with these issues is an essential foundation and as such should be the immediate policy and practice imperative for the nursing leadership. Only then will it be possible to determine the models of care delivery best able to balance cost and quality in different contexts and to achieve progress in the educational and regulatory frameworks necessary to support it.