‘Moral Failing’ in Nursing?

The NHS is often in the news, and not always for the right reasons. Health care staff are working hard to keep the ship afloat but do so often at great personal cost due to stress and burnout. Unison (2014), in their report ‘Running on Empty. NHS staff stretched to the limit‘ outline the reported conditions in which NHS staff are giving care. It is not good reading. Two quotes illustrate the situation:

“Every day we struggle with beds . Constant harassment from managers to free beds and discharge patients, sit patients out of bed, etc . There is no time for anything meaningful. Managers are obsessed with targets . Targets don’t measure quality of care .”

and

“On occasions, staffing levels are bordering on dangerous.  We are in a Mid Staffs situation and I don’t believe we are the only ones.”

In 2013 the RCN published a similar report ‘Beyond Breaking Point‘ in which it is suggested that patient care is under pressure from nurses’ stress.

However, Dan Poulter of the coalition government have argued that although the NHS faces challenges, the “health service is bearing up and treating people very well“. This may well be true. The quality of care may well be good to excellent. The King’s Fund suggests:

“…in broad terms the NHS has continued to provide services to a growing population and to maintain the quality of those services. However, there is deepening pessimism about the ability of the NHS to make ends meet financially, particularly in 2015/16”.

Talk about crisis may be premature, but it may well be the case that patients are getting good care despite, and not because of, the structures and finances to support staff giving that care. patients may be getting care at the expense of the wellbeing of some staff.

This may well have always been the case. One long standing description of nursing may not have been helpful in the past, but due to changed circumstances, may now have become an out dated and indeed injurious conception of what nursing now is. This description of nursing as individual moral work, or perhaps otherwise called a ‘vocation’,  is under now under continued scrutiny.

Much has been written about Mid Staffs and perhaps this is fading into history. However, for nurses the underpinning pressures on them remain. Michael Traynor (2014)  in a recent article highlights one of those pressures: the identification of nursing as ‘character based moral work’. This is reflected also in the United States in that some states require assesment of ‘good moral character’ for licensure to practice. In the UK the purpose of ‘values based recruitment‘ is:

“…to ensure that we recruit the right workforce not only with the right skills and in the right numbers, but with the right values (my emphasis) to support effective team working in delivering excellent patient care and experience”.

There is nothing intrinsically wrong with this approach. In fact I would hope that all health care staff, and indeed all of us, come to work with ‘good moral character’ while holding the appropriate values. This applies to a taxi driver as well as to politicians.

For nurses, however this emphasis on their work as ‘character based moral work’, supported by University recruitment that focuses on those with a ‘caring orientation’,  may operate to deflect analysis of the systems of work that result in ‘cognitive, professional, bureaucratic and work’ pressures (Traynor 2014) which may, for too many, result in stress and burnout. Failings in care are also seen in these terms – i.e. that of the individual failure of the moral character of the nurse.

Traynor’s argument is that:

1.  Nursing failures are possibly an inevitable consequence of work in health systems  under pressure.

2, Nursing is often viewed as primarily ‘character based moral work’, to an extent not applied to other occupations.

3. The profession focuses on recruiting those with a caring orientation but does not equip these new recruits with an adequate understanding of the causes of inadequate practice.

4. This leads to acquiescence to poor standards and hinders the development of ‘critical resilience’.

Student nurses learn about the legal and ethical basis for care, they study leadership and management theory, they address quality enhancement as well as developing clinical skills. They do so often without a critical theory of the context of the care system they enter and often face moral distress when the care they want to give is bounded by the myriad pressures they and their mentors face in reality. Instead personal accountability is stressed and their individual moral character is scrutinised. Before they can register a declaration of good character has to be signed. All of this is blind to the reality of practice.

Perhaps it is time to reexamine the chimera of ‘character based moral work’, divest ourseleves of this misleading description of the basis of nursing practice and instead use our sociological imaginations to develop political and critical resilience in student nurses.

I may warm to this theme.

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