Tag: Care

Hunt on care as a ‘commercial opportunity’.

You have been paying NI all your life. it was never going to be enough to fund the increases in life expectancy or the number of years experienced as frail. Care is currently a commodity in a failing market. The answer may lie in a mix of not for profit social enterprises, charities and private insurance schemes. We could of course socialise the risk and pool resources through the general taxation system so that we share costs. That however is a political decision not favoured currently. ‘For profit’ providers have so far shown to be not up to the job as LA funding decreases and costs go up. This is a sector characterised by low status, low pay and little training, staffed mainly by women as an extension of domestic labour who often provide care to residents over and above their pay as a ‘gift’. Hunt is right: this is a ‘big commercial opportunity‘ – as is the hotel service sector. They share the same experience for its workers: low status, low pay and dirty work. Owners and shareholders will rub their hands with glee if they can get the same profits out of care as they can hotels. They will call for labour market ‘flexibility’ to continue, and light touch regulation to keep costs down. There is no getting around the fact that care costs individuals their time and labour to provide. If society designs itself in such a way that this time and labour will be provided free, and by women, then this society is exploitative. Care is vital, it is ‘social reproduction’ without which we all perish. Seeing it only through the prism of ‘commercial opportunity’ devalues this vital life force, but I expect nothing more from this bunch of privileged elite millionaires who will no doubt not flinch in paying for care at Savoy Hotel standards while the rest of us sit in pool of piss.

Nursing care scares and Moral Panic

Nursing, Care scares and Moral Panic.

 

The number and tone of reports of poor quality care (e.g. Simmons 2011) especially, since the Mid Staffs NHS trust inquiry but by no means is defined by it, may be described as a moral panic and has been described as a crisis in care (Hari 2011, Phillips 2011a, 2011b) and “reveal a moral sickness in the professional ethic of nursing, and more particularly nurse training…” (Phillips 2011b). These media reports over poor quality care (Marrin 2009, 2011, Shields et al 2011) and the identification of graduate nurses as folk devils who are “too posh to wash”, lead us to ask why this moral panic over graduate nursing has arisen?

 

A ‘moral panic’ is when a population feels the ‘social order’ is threatened, and that this threat is felt intensely, it is a certain reaction to a perceived social problem. A moral panic may be characterized by irrational, inappropriate overreactions to problems. Stanley Cohen (1972) applied the term to press reports and establishment reaction to the phenomenon of ‘Mods and Rockers’, a moral panic arises when:

 

“a condition, episode, person or group of persons emerges to become defined as a threat to societal values and interests” (Cohen 1973 p9). The scathing criticism of graduate nursing in the press looks very similar to this sort of description. So, what societal values and interests are thought to be threatened by graduates?

 

The first aspect is that some feel a loss of ‘the proper place of women/nurses as mother archetypes’ which is part of the longer term process of female entry into the labour market and the break from domestic duties. Feminism has been blamed for this process (however the requirements of consumer capitalism and the need for labour has also had its effects).

 

The second is the ambiguities felt over the care of elderly people which increasingly has been seen to be the State’s proper role since the introduction of the Welfare State. Although the expressed social order demands that care of the elderly be done within families, the economy demands labour mobility resulting in geographically fragmented families unable to care for elderly relatives. The loss of the family wage and the rise of consumer culture also affects our abilities to care for both children and the elderly as both parents work. The actual social order is that elderly people are, en masse, in institutions and that allows us to abrogate our responsibilities. Although no one expresses a wish to be in a nursing home, no-one either wants (or is able) to take responsibility for elder care.

 

The third aspect is that body work which involves intimacy, closeness as well as dirt and disgust, is again seen as female caring work which does not attract any social value or support beyond expressions of stoic heroism on behalf of carers.

 

Graduate nurses challenge these conceptions by being women who are educated, who work and expect like any other professional to be rewarded for their efforts, there is then a cognitive dissonance between on the one hand a vision of nursing as self sacrificial angels and as professionals requiring proper education and reward as professionals. One way to solve this dissonance is to reframe professional nursing, i.e. ‘train’ them in hospitals (putting them in their ‘proper place’).

 

However, the place of women, and women as nurses, the ambivalence towards care and its meaning, the increasing marginalisation of the elderly and their devaluing may be manifestations of society’s turn from solid to ‘liquid modernity’ (Baumann 2000). Social values, aspirations and expectations are played out within the themes of globalization, individualization, marginalisation, poverty and consumerism. These are the actual social threats that this moral panic cannot actually name and identify. ‘Folk devils’ have to be found to explain these new forms of alienation. Poor care has been around as long as there have been carers, and so we need to be careful not to argue that liquidity causes poor care, rather it may the case that liquid social conditions predispose individuals to perform in particular ways and for their actions to be interpreted in particular ways. The folk devils are in, this instance, graduate nurses. However, blaming nurses refocuses attention away from more difficult problems and gives easy solutions (‘return training to hospitals and all will be well’).

 

Liquid modernity, according to Baumann, involves community fragmentation, eroding social bonds, atomized relationships and individualistic expectations all in the context of the globalization of capital and markets which dislocate communities. Workers have to respond to calls for mobility and flexibility or face redundancy. Communities struggle to reconcile competing demands especially with the increasing numbers of elderly people and costs of care. Nurses and midwives find themselves caught between all of these competing demands unable to make the links between their individual experiences and larger social conditions,

 

If only one nurse abuses a patient we should properly look to the character of the individual nurse for reasons.  When cases of reported abuse become legion then the personal troubles of the patients should be seen in the context of the public issues of society. To fully comprehend the position of the abuser we need to address their personal biography and history and the relationship between the two in society. Anyone wishing to analyze why there is poor care needs to avoid simplistic knee jerk moral panic type reactions and grab the idea that nurses can understand their experiences and gauge their fates only by locating themselves within their period, that they can know their  own lives only by becoming aware of all those nurses in the same circumstances. Focusing on the personal accountability of care staff without addressing the structural conditions in which they work simply will not do.

 

So what then is the answer?

 

Care has to be really valued, and in current society the main way value is ascribed is to place a monetary value onto it and bring it centrally into business planning. Therefore the cost of care has to be brought into all accounting. Capitalist production currently does not take into account the care (and environmental) costs that society bears for that production. However caring still has to be done or else production cannot continue in its current form. This is not a new argument, feminists and environmentalists have been arguing this for years. If society wishes to value care then it has to pay for it. That means increasing the number of staff and paying them a competitive wage so that good quality staff are educated, retained, supervised, developed and valued. Or, as Sue Gerhardt (2010a) agues we should refocus on caring as a real social value and perhaps introduce a ‘caring wage’ (2010b) say £12,000-£16,000 per year? Society has to value care with more than lip service and the stoic angels tag, but in the current economic setting social values are not strong enough to ensure we will do this.

 

 

 

 

 

 

 

Baumann Z. (2000) Liquid modernity. Polity. Cambridge.

 

Cohen, S. (1973). Folk Devils and Moral Panics. St Albans: Paladin, p.9

 

Gerhardt S. (2010a) The Selfish Society. How we all forgot to love one another and made money instead. Simon and Shuster. London.

 

Gerhardt S.(2010b) The Selfish Society. RSA events. 22nd April. http://www.thersa.org/events/audio-and-past-events/2010/the-selfish-society

 

Hari, J. (2011) The plan to resolve our care home crisis. The Independent January 26th http://tinyurl.com/5ugyond

 

Hawken P (1994) The Ecology of Commerce. Harper Collins. London

 

Marrin, M. (2009) Oh Nurse, Your degree is a symptom of equality disease. The Sunday Times. November 15th

 

Marrin, M. (2011) Our flawed uncaring NHS is a self inflicted wound. The Sunday Times. May 29th

 

Phillips, M (2011) The moral crisis in nursing, voices from the wards. Daily Mail. October 21. http://melaniephillips.com/the-moral-crisis-in-nursing-voices-from-the-wards

 

Phillips, M. (2011) How feminism made so many nurses to grand to care. Daily Mail. October 17. http://melaniephillips.com/how-feminism-made-so-many-nurses-too-grand-to-care

 

Shields, L., Morrall, P., Goodman, B., Purcell, C. and Watson, R. (2011) Care to be a nurse? Reflections on a radio broadcast and its ramifications for nursing today. Nurse Education Today. doi:10.1016/jnedt.2011.09.001

 

Simmons, M. (2011) Poor Nursing care. NursingTimes.net. 4th July. http://www.nursingtimes.net/poor-nursing-care/398.thread

Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study

Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study

Young Nurse Tending to Young Woman with Neck Brace and Arm Cast

 

“Nurse staffing cuts to save money might adversely affect patient outcomes. An increased emphasis on bachelor’s education for nurses could reduce preventable hospital deaths”

This is not the only study to suggest this. Not only is the nurse to patient ratio an important factor in reducing patient mortality after surgery, their education they have is also a factor. Degree nurses have a positive impact on reducing mortality after surgery. This should finally nail the ‘you don’t need a degree to nurse’ nonsense. This is an argument that nurses have used when decrying poor standards of care.

 

Government, Society, Hospital Management and even nurses themselves need to realise their true worth as educated professionals. Care costs money, and if you scrimp on that and put pressure on staff, then you get worse mortality rates.

 

I often read comments by nurses that the problem with nursing today is education – ‘too posh to wash’ or ‘graduates lack compassion’ or ‘not enough clinical skills’ or a variant. This is nonsense and plays into the hands of those who want a cheaper workforce by increasing the care assistant to nurse ratio. If someone is too posh to wash or lacks clinical skills it is not because they are graduates. It is for other reasons, such as burn out, stress, lack of empathy or compassion per se. I’ve known many non graduate nurses who display lack of compassion, poor clinical skills and avoid washing patients. There was no ‘golden age’ of nursing when all you needed was ‘the right attitude’ and training by doctors.

Today, the evidence is stacking up – employ more RNs and get them educated!

Do you want to be nursed by someone who can take a blood pressure but can’t interpret it? No? Thought not. I once was told by a member of staff, after taking my blood pressure and being asked what it was, just a few hours after surgery,  “don’t ask me, I’m only a care assistant”.

On the same day that the Lancet study was published the Royal College of Nursing also published the result of a staff survey, now bearing mind the validity of self reported surveys, the findings do not sit well alongside the above study.

“Only 30 per cent of staff think there are enough staff to enable them to do their jobs properly and 82 per cent of nurses continue to work extra hours. 68 per cent of staff have attended work while not being well enough to perform their duties in the last three months alone.”

Another reading of that is the 70% of staff do think they have enough staff, but it is hard to spin the 82% reporting working extra hours. The issue regarding Mid Staffs reported in the media 26th February,  also highlighted the financial difficulties many Trusts are facing and following the Nicholson challenge, continue to do so. Although there are claims about the recruitment of more nurses into the NHS, the context is still one of pressure on the front line.

This directly affects nurse educators as we struggle to support mentors in practice to up the quality of students’ support and assessment. Our Placement Development Team colleagues who have the overview, can tell us both the hard data and soft metrics of the truth of clinical practice support – the areas where students can shine and feel supported and where they don’t.

We therefore still have a political battle to get results from studies such as this taken seriously by decision makers and key stakeholders. Evidence based policy on many health, social care, climate change, drugs and other issues is sadly lacking, instead we get policy driven evidence driven through by one of the most partisan, ideologically focused governments even since Thatcher. This Lancet paper will be of interest to us, but I wait without too much hope that Hunt et al will sit up and take any notice.

 Jane Salvage recently wrote “Nurse and scholar Jane Robinson and sociologist Phil Strong suggested (that nurses were invisible) in their study of the management of nursing following the introduction of general management. They suddenly realized, they said, that ‘despite the impressive statistics… nursing is relatively unimportant to government and to managers in comparison with medicine.’ They went on, ‘The tensions to which this situation gave rise – the nursing group locked into the gravitational force of its internal preoccupations, and the others, on the outside, unable or unwilling to look in and comprehend the nature of nursing’s dilemmas – seemed to us to be the social equivalent of an astronomical Black Hole’ (Robinson 1992)” .

1992. I don’t think much has changed.

 

An unachievable utopia in nursing practice? Utopia will not be paid for by the ‘Greedy Bastards’

The Politics of Nursing: Care is expensive: get used to it.  

Introduction

By now many nurses will be feeling a mixture of despair and insult they have received following the many reports into poor quality care. These feelings can lead to disenchantment, disengagement and disillusionment with both politics and health care delivery. Jane Salvage (1985) suggested that nurses ‘wake up and get out from under’ and while recognising that for some this past entreaty to engage politically may further entrench those feelings, the need for nurses and nursing to do so has not diminished. As Stuckler and Basu (2010) argue, government policy becomes a matter of life and death as ‘Austerity is killing people’. Nurses are part of the front line in promoting health and caring for those who are ill or living with chronic conditions. Their work is therefore framed by politics and political decisions. The bottom line is that there is a ‘bottom line’ to care, societies prioritise resources depending on their values, however there is not a level playing field in this regard. Care is under resourced, undervalued and often invisible. As millions of people in the UK, and billions across the globe, experience a daily struggle to both give and receive care Nursing must ally itself with the progressive forces which seek to redress the balance forces of power which currently results in gross inequalities in health and poorly funded care provision. In this article I wish to remove the ‘flowers from the chains’ so that we more clearly see what holds us back from progress in care giving.

The Politics of care

This summary of a recent article by Curtis (2013) is worth reading as it sets up what some are experiencing as they struggle to reconcile care and the cultures that surround it:

“Nursing faculty are facing challenges in facilitating student learning of complex concepts such as compassionate practice. There is currently an international concern that student nurses are not being adequately prepared for compassion to flourish and for compassionate practice to be sustained upon professional qualification…..nurse teachers recognise the importance of the professional ideal of compassionate practice alongside specific challenges this expectation presents. They have concerns about how the economically constrained and target driven (my emphasis) practice reality faced by RNs promotes compassionate practice, and that students are left feeling vulnerable to dissonance between learned professional ideals and the RNs’ practice reality they witness”.

A key point made in the article is that of the requirement for strong nurse leadership in clinical practice to deal with those factors that make care and compassion difficult to practice fully. That being said, no amount of good leadership will address the basic problem of the cost of caring: ‘who pays?’ Poor quality care is the fault of the person giving it, personal accountability for neglect and abuse cannot be sidestepped. However, we need to bring our sociological imaginations to bear so that we can more fully understand the antecedents to abusive institutional care. These include poorly funded care provision for a low status Cinderella service.

Too much of the discussion of the failings in care do not take into account the political economy of care in societies and the historical antecedents that have brought us to where we are. Instead, we get discussions around changing ‘cultures’. Reconciling professional ideals to actual practice is very difficult given the organisational cultures many nurses work in, and the almost grudging support given to nurses by the political system set up by what Graham Scambler (2012) calls the Corporate Class Executive (CCE) and the Political Power Elite (PPE). The bottom line, and that is a phrase the CCE recognise, is that care costs money. One of the critiques of the Mid Staffs tragedy was that corporate self-interest was put ahead of patients’ safety (Francis (2013).

There have been many reports regarding the health and social care of elderly people and it seems to be that their needs are outstripping both private and public provision for them. J K Galbraith coined the phrase ‘private affluence-public squalor’ to describe the mismatch between what is resourced in the private sector and the public:

There’s no question that in my lifetime, the contrast between what I called private affluence and public squalor has become very much greater. What do we worry about? We worry about our schools. We worry about our public recreational facilities. We worry about our law enforcement and our public housing. All of the things that bear upon our standard of living are in the public sector. We don’t worry about the supply of automobiles. We don’t even worry about the supply of foods. Things that come from the private sector are in abundant supply; things that depend on the public sector are widely a problem. We’re a world, as I said in The Affluent Society, of filthy streets and clean houses, poor schools and expensive television. I consider that contrast to be one of my most successful arguments”. (interviewed in 2000).

Galbraith first wrote about this process in 1958.

As governments embrace austerity policies, this tendency for capitalism to funnel resources, research and development into goods and services that make a return while ignoring public provision for those things that do not have immediate impacts on improving shareholder value or the price of stocks, increases. Care is seen as a cost and not a benefit to those who decide where the investments should be made. Private care companies will provide care with an eye to the balance sheet. This results in hiring under educated and poorly trained staff who too often lack supervision and development in high patient to staff ratios (Salvage 2012). The NHS is no different, but is also now handicapped by various factors making its provision seemingly expensive for society. While the current (2013) Chancellor states that NHS spending will be ringfenced, the true position is that care straddles both health and social care sector provision and is thus characterised by means testing.  It is accepted fact that our population is ageing with forecast increases in dementia and diabetes, health and social care services will experience increased pressures as demands and frailties rise. The argument is about who is going to pay for the provision of care?

Frail elderly people need a lot of care and that care is expensive. Let us not forget our history – why the NHS was set up (Abel Smith 2007), who struggled to get it in into place and why, and the functions women especially played in the private sphere (Elshtain 1981) of care both for children and the elderly. Modern Industrial society was both capitalist and patriarchal with care firmly in the private domain. No state funding as we would recognise it was provided because this was expensive. Patriarchal attitudes would not define it as ‘proper’ work and so could be left to women. The Parish, Poor laws and workhouses were the backstop for those unable to fend for themselves, for those without the family, and that often meant women, looking after them. The working class had to struggle to get health and education properly funded. Enlightened Victorian philanthropists and entrepreneurs realised that if they wanted workers to keep working then recreation and education had to be provided. This provision was despite the capitalist dynamic for profit, not because of it.

We have come a long way as social democratic pressures finally provided the NHS and Education, as the elites also were won over to the need to provide care. The ‘One nation’ Tories at least understood that a prosperous society had to take care of all of its members, of course there was some self interest in this – we needed soldiers who were fit for the battlefield, and we needed healthy workers for the factories. This is a simplistic history as it is more nuanced than this. However, over the last 30 years or so we have seen reversal of this enlightened social democratic outlook on care and public health and care. The need for care is increasing but this is occurring just when the elites are pulling back from their responsibilities. They look at what state provision will cost for high quality elder care and are frightened.  They also have a visceral loathing of state provision…because it costs them money through taxes they do not want to pay. They say it is because the state is inefficient and anti-democratic, that state provision is the road to serfdom. Suffice to say that the current involvement of the CCE with the PPE is extremely antidemocratic but their right wing press cheerleaders have not spotted it or prefer to ignore it.   Seamus Milne  has eloquently exposed how corporate power is corrupting politics.

The neoliberal capitalist agenda (Crouch 2011) requires the state to pull back from earlier involvement on education and health. The CCE and the current PPE have swallowed an ideology that simply accepts private provision = good, public provision = bad. This is why we are seeing the conditions of an affluent society being characterised by a hugely increasing wealth gap. This agenda also allies itself with patriarchal views on the proper role for women – get back in the kitchen girls and look after the kids…and now, of course, Gran as well.

Austerity is now the smokescreen for dismantling of the state provision for care. Does this mean that lack of compassion is directly related to neoliberal policies?  To accept that is to think in an overly simplistic cause effect relationship. Societies are more complex than that.  Of course poor quality care pre dates capitalism and the NHS, however capitalism (and its often hidden twin patriarchy) sets the agenda and the organisational forms and institutional arrangements in which care takes place. This now means as budgets get cut and savings asked for, nurses will be asked to provide more for less. This has been always the case; nursing work as womens’ work (Hagell 1989) has largely been invisible emotional labour (Smith) which has been poorly paid and supported, instead their rewards have been patronising labels such as ‘Angels’. Nurses know what they need to provide care and they can do it if given supportive organisational cultures and the power to actually direct, organise and manage care properly.

As Roy Lilley argued on nhs.managers.net:

(The Francis report 2013) talks about ‘culture change’. Effectively making the people we have make the services we’ve got, work better. On that basis Francis fails. What we’ve got doesn’t work. Never will.  Think about it; nearly all the quality problems the NHS faces are around the care of the frail elderly. Why? Because the NHS was never set up to deal with the numbers of porcelain-boned, tissue paper skinned elderly it is trying to cope with. The NHS’ customer-base has changed but the organisations serving them have stood still.

and…

“Fund the front-line fully, protect it fiercely, make it fun to work there, that way you’ll make Francis history.”

And there you have it. Do the austerity addicts think it is the proper role of the state to fund the front line. No, they hanker after a US style private provision with the family, the big society volunteers and women to take up the slack. That will not wash in a hospital ward or a care home full with frail elderly patients.

Nurse educators and their students do not work in a socio-political vacuum. However, one would think that they do if the content of curricula and the learning experiences planned are anything to go by. Indeed any discussion around political economy, patriarchy and capitalism is liable to be met with surprise, apathy, disdain apart from those engaged in teaching the social sciences in nursing. I would argue that nursing cannot shy away from addressing these questions. Nurses as women, who experience the requirements to care in both their domestic and public lives, bear the brunt of the demands of a society which needs that care to be done but is unwilling to fully fund it. It might be fair to suggest that since about the 1980’s both feminism and social democratic politics took their eyes off the ball or felt that because progress had been made the struggle was nearly over.  It is not. We need to argue for the social value of care and against privatised individualised provision which falls unfairly on the shoulders of those who often do not have the resources to provide it.

Caring is not sexy – it is not fancy infrastructure projects, it does not make millions at the click of a mouse;  hedge funds and private equity firms don’t crack champagne bottles over the needs of the frail elderly. Care is unglamorous emotional labour, involves often dirty body work, offering little in the way of recognition and prizes – there are no Golden Globes, Oscars or Baftas. There is no end point, no project that is completed and shown off, no bonuses to be earned. ‘Top’ Universities show off their ‘top’ professions: law, medicine, business and science whose courses are oversubscribed due to professional closure and the high salaries they attract. The children of the elite are groomed and public schooled to ensure they attend the ‘right University’ and study the ‘right’ subject while eschewing nursing, which struggles to gain academic credibility and value among society and Russell group elites, while its core concept is seen to require no education at all.

Nurses are in a political struggle whether they realise it or not. For the sake of all us who will require care, don’t let the greedy bastards grind us down

 

 

 

 

 

References:

Abel Smith, B. (1992) The Beveridge Report: its origins and outcomes. International Social Security Review 45 (1-2) pp5-16

Curtis, K. (2013) 21st Century challenges faced by nursing faculty in educating for compassionate practice: Embodied interpretation of phenomenological data.   Nurse Education Today, http://www.nurseeducationtoday.com/article/S0260-6917%2813%2900170-6/abstract

Elshtain, J. (1981) Public Man, Private Woman: Women in Social and Political Thought. Princeton, NJ: Princeton University Press

Scambler, G. (2012) Elements towards a Sociology of the Present. December 6th http://grahamscambler.wordpress.com/2012/12/06/elements-towards-a-sociology-of-the-present/

The NHS needs Registered Nurses. Patients need Registered Nurses

 

First let’s deal with the title ‘Nurse’. In the UK it is illegal to call yourself a nurse if you are not on the register, Nurse is a legally protected title…this is a fact which gets lost in media talks about poor ‘nursing’.

Too much ‘nursing’ is in fact done by care assistants.

Too many student nurses are being supervised by care assistants.

Care assistants often are good people trying their best but they are not always supported, trained or supervised enough. They need to support nurses in their roles rather than replace them, which is in fact what is happening.

In ‘Skill mix and the effectiveness of nursing care’ Carr-Hill (1992) argued that ‘grade mix had an effect on the quality of care in so far as the quality of care was better the higher the grade (and skill) of the nurses who provided it’. In other words skilled nurses reduce poor quality care.

In the United States a Philadelphia hospital (2012) adopted an all RN care model, they eliminated the use of care assistants and patient outcomes improved and costs reduced.

This comes on the back of another 2006 in the US  study indicating that increasing the ratio of nursing by RNs reduces stay, adverse outcomes and patient deaths.

Finally as published on the nursingtimes.net a UK study suggests:

“There is a link between higher death rates and the number of healthcare assistants employed in NHS hospitals”.

A study by the University of Southampton found trusts with a higher number of unregulated HCAs also had a higher mortality rate.

A higher HCA-to-bed ratio increased the mortality rate up to a maximum of 5.4% more than would be expected, the new study found.

The study also identified a clear link between the number of registered nurses and mortality. It found there were fewer deaths the more nurses were employed. For every 10% increase in the number of registered nurses the odds of patients dying dropped by almost 7%.

Based on hospital admissions in 2010-11, the study found a 10% increase in the number of nurses would result in 2,600 fewer deaths.

Lead study author Professor Peter Griffiths told Nursing Times the findings on HCAs needed further investigation, but said: “It certainly calls into question a workforce strategy that moves registered nurses further away from the bedside and replaces them with assistants.

“This echoes some of the findings of the [Mid Staffordshire Public Inquiry] report, which expressed concern over the lack of regulation for this workforce.”

Professor Griffiths added: “The fewer registered nurses a hospital has, the more patients die. So the significance of nurse staffing levels seems to be well established both in the research and in the tradition of the profession.”

He added that, while the government appeared “dead set” against introducing mandatory staffing levels, “there is surely a level at which we can be clear it cannot be safe under any circumstances.”

He suggested a ratio of eight patients per nurse, saying in his study 60% of shifts were at this level or better.

“The findings taken as a whole point to the need for more qualified nurses at the bed side,” Professor Griffiths said. “It is hard to conclude from this evidence that the solution lies in downgrading the training of the nursing workforce as a whole and reducing the number of registered nurses.”

On Graduate nursing:  

http://jama.jamanetwork.com/article.aspx?articleid=197345 ?

Reference Aiken et al (2003) Educational Levels of Hospital Nurses and Surgical Patient Mortality. JAMA 290(12):1617-1623

June Girvin argues:  The evidence clearly shows that graduate nurses offer better care than non-graduates and the more highly skilled and educated nurses there are in clinical areas, the better care outcomes are. The tendency to attack the academic elements of nurse education as being at the root of the current perceived crisis in care has no place in modern healthcare environments.

‘Nuff said.

Nursing, Care scares and Moral Panic.

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The number and tone of reports of poor quality care (e.g. Simmons 2011) especially, since the Mid Staffs NHS trust inquiry but by no means is defined by it, may be described as a moral panic and has been described as a crisis in care (Hari 2011, Phillips 2011a, 2011b) and “reveal a moral sickness in the professional ethic of nursing, and more particularly nurse training…” (Phillips 2011b) .These media reports over poor quality care (Marrin 2009, 2011, Shields et al 2011) and the identification of graduate nurses as folk devils who are “too posh to wash”, lead us to ask why this moral panic over graduate nursing has arisen?

 

A ‘moral panic’ is when a population feels the ‘social order’ is threatened, and that this threat is felt intensely, it is a certain reaction to a perceived social problem. A moral panic may be characterized by irrational, inappropriate overreactions to problems. Stanley Cohen (1972) applied the term to press reports and establishment reaction to the phenomenon of ‘Mods and Rockers’, a moral panic arises when:

 

“a condition, episode, person or group of persons emerges to become defined as a threat to societal values and interests” (Cohen 1973 p9). The scathing criticism of graduate nursing in the press looks very similar to this sort of description. So, what societal values and interests are thought to be threatened by graduates?

 

The first aspect is that some feel a loss of ‘the proper place of women/nurses as mother archetypes’ which is part of the longer term process of female entry into the labour market and the break from domestic duties. Feminism has been blamed for this process (however the requirements of consumer capitalism and the need for labour has also had its effects).

 

The second is the ambiguities felt over the care of elderly people which increasingly has been seen to be the State’s proper role since the introduction of the Welfare State. Although the expressed social order demands that care of the elderly be done within families, the economy demands labour mobility resulting in geographically fragmented families unable to care for elderly relatives. The loss of the family wage and the rise of consumer culture also affects our abilities to care for both children and the elderly as both parents work. The actual social order is that elderly people are, en masse, in institutions and that allows us to abrogate our responsibilities. Although no one expresses a wish to be in a nursing home, no-one either wants (or is able) to take responsibility for elder care.

 

The third aspect is that body work which involves intimacy, closeness as well as dirt and disgust, is again seen as female caring work which does not attract any social value or support beyond expressions of stoic heroism on behalf of carers.

 

Graduate nurses challenge these conceptions by being women who are educated, who work and expect like any other professional to be rewarded for their efforts, there is then a cognitive dissonance between on the one hand a vision of nursing as self sacrificial angels and as professionals requiring proper education and reward as professionals. One way to solve this dissonance is to reframe professional nursing, i.e. ‘train’ them in hospitals (putting them in their ‘proper place’).

 

However, the place of women, and women as nurses, the ambivalence towards care and its meaning, the increasing marginalisation of the elderly and their devaluing may be manifestations of society’s turn from solid to ‘liquid modernity’ (Baumann 2000). Social values, aspirations and expectations are played out within the themes of globalization, individualization, marginalisation, poverty and consumerism. These are the actual social threats that this moral panic cannot actually name and identify. ‘Folk devils’ have to be found to explain these new forms of alienation. Poor care has been around as long as there have been carers, and so we need to be careful not to argue that liquidity causes poor care, rather it may the case that liquid social conditions predispose individuals to perform in particular ways and for their actions to be interpreted in particular ways. The folk devils are in, this instance, graduate nurses. However, blaming nurses refocuses attention away from more difficult problems and gives easy solutions (‘return training to hospitals and all will be well’).

 

Liquid modernity, according to Baumann, involves community fragmentation, eroding social bonds, atomized relationships and individualistic expectations all in the context of the globalization of capital and markets which dislocate communities. Workers have to respond to calls for mobility and flexibility or face redundancy. Communities struggle to reconcile competing demands especially with the increasing numbers of elderly people and costs of care. Nurses and midwives find themselves caught between all of these competing demands unable to make the links between their individual experiences and larger social conditions,

 

If only one nurse abuses a patient we should properly look to the character of the individual nurse for reasons.  When cases of reported abuse become legion then the personal troubles of the patients should be seen in the context of the public issues of society. To fully comprehend the position of the abuser we need to address their personal biography and history and the relationship between the two in society. Anyone wishing to analyze why there is poor care needs to avoid simplistic knee jerk moral panic type reactions and grab the idea that nurses can understand their experiences and gauge their fates only by locating themselves within their period, that they can know their  own lives only by becoming aware of all those nurses in the same circumstances. Focusing on the personal accountability of care staff without addressing the structural conditions in which they work simply will not do.

 

So what then is the answer?

 

Care has to be really valued, and in current society the main way value is ascribed is to place a monetary value onto it and bring it centrally into business planning. Therefore the cost of care has to be brought into all accounting. Capitalist production currently does not take into account the care (and environmental) costs that society bears for that production. However caring still has to be done or else production cannot continue in its current form. This is not a new argument, feminists and environmentalists have been arguing this for years. If society wishes to value care then it has to pay for it. That means increasing the number of staff and paying them a competitive wage so that good quality staff are educated, retained, supervised, developed and valued. Or, as Sue Gerhardt (2010a) agues we should refocus on caring as a real social value and perhaps introduce a ‘caring wage’ (2010b) say £12,000-£16,000 per year? Society has to value care with more than lip service and the stoic angels tag, but in the current economic setting social values are not strong enough to ensure we will do this.

 

 

 

 

 

 

 

Bauman Z. (2000) Liquid modernity. Polity. Cambridge.

 

Cohen, S. (1973). Folk Devils and Moral Panics. St Albans: Paladin, p.9

 

Gerhardt S. (2010a) The Selfish Society. How we all forgot to love one another and made money instead. Simon and Shuster. London.

 

Gerhardt S.(2010b) The Selfish Society. RSA events. 22nd April. http://www.thersa.org/events/audio-and-past-events/2010/the-selfish-society

 

Hari, J. (2011) The plan to resolve our care home crisis. The Independent January 26th http://tinyurl.com/5ugyond

 

Hawken P (1994) The Ecology of Commerce. Harper Collins. London

 

Marrin, M. (2009) Oh Nurse, Your degree is a symptom of equality disease. The Sunday Times. November 15th

 

Marrin, M. (2011) Our flawed uncaring NHS is a self inflicted wound. The Sunday Times. May 29th

 

Phillips, M (2011) The moral crisis in nursing, voices from the wards. Daily Mail. October 21. http://melaniephillips.com/the-moral-crisis-in-nursing-voices-from-the-wards

 

Phillips, M. (2011) How feminism made so many nurses to grand to care. Daily Mail. October 17. http://melaniephillips.com/how-feminism-made-so-many-nurses-too-grand-to-care

 

Shields, L., Morrall, P., Goodman, B., Purcell, C. and Watson, R. (2011) Care to be a nurse? Reflections on a radio broadcast and its ramifications for nursing today. Nurse Education Today. doi:10.1016/jnedt.2011.09.001

 

Simmons, M. (2011) Poor Nursing care. NursingTimes.net. 4th July. http://www.nursingtimes.net/poor-nursing-care/398.thread

 

 

 

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