Too posh to wash? Reflections on the future of Nursing.
“When…only one man is unemployed, that is his personal trouble, and for its relief we look to the character of the man, his skills and his immediate opportunities. When…15 million…are unemployed, that is an issue, and we may not hope to find the solution within the range of opportunities open to any one individual…Both the correct statement of the problem and the range of possible solutions require us to consider the economic and political institutions of society and not merely the personal situation and character of a scatter of individuals”. (C Wright Mills – The Sociological Imagination p9).
In the many contributions to the debate about poor quality care, there is often a distinct lack of a sociological imagination. While individuals can be rightly criticised for giving poor care, the antecedents are to be found beyond the personal trouble of individual nurses and their patients, and can be classed as a public issue: that of the political, social and economic failures of the governing, managerial and administering classes over the past few decades.
‘Too posh to wash’ is the title of a recent publication on the condition of nursing in 2013 and reflects newspaper headlines and the Health Minister, Jeremy Hunt’s, call to student nurses in March 2013. In it there is a range of contributions from various practitioners and experts on the delivery of care in the UK. They were asked to address various questions:
1. Why do we have lapses in nursing care and what needs to be done to prevent poor care back into caring?
2. In striving for professionalism have we over qualified yet undertrained today’s nurse? Are they too posh to wash? What mechanisms and support systems need to be in place to ‘bring excellence’ back into the profession?
3. Has the role of the nurse leader been devalued? Has respect for their knowledge and expertise and a desire to emulate them decreased?
4. Why have boards within both NHS and non-NHS organisations appeared to have failed to deliver the expected improvements in quality of care? Are board members unaware of the standards on their wards or in their care settings?
Various issues and solutions were raised but the answer to the title appears to be: “no”, students are not too posh to wash. The myth of a golden age was shown to be just that – a myth. Menzies Lyth’s 1960 paper was quoted and is still worth a read today. I would also refer to Kath Melia’s work around the challenges students faced nearly three decades ago.
Among the normative statements made, i.e. what nurses ‘ought’ and ‘should’ do, there was some attempt at analysis of underlying reasons for poor care. This included societal attitudes to ageing and caring, and technology and is affects on communication. There was no call however to return to apprenticeship training outside the University. This accords with the findings of the Willis Commission (2012).
What was striking was the almost passing references to systemic failures within the NHS around the structures for providing care. These failures are the responsibility of the governing political and managerial classes who are charged with running the NHS. While we are acknowledging ageing populations, increasing frailties and complex care needs, there is a a requirement to examine the context of care. To examine what structures have been put in place to deliver care to increasing numbers of frail elderly people in acute hospitals and care homes. Student nurses in particular are placed in clinical practices which are not conducive to compassionate care, and are often the least equipped to understand, analyse and bring about change.
Universities can support the development of critical thinking and underpinning knowledge but are almost powerless to affect this care context in which students find themselves. No amount of curricular changes emphasising compassion and caring will work if students continue to experience Melia’s 1984 and Lyth’s 1960 descriptions of the care environment.
Menzies Lyth (1960) argued that nurses experienced high levels of anxiety due to their work and that there was an absence in the hospital of any mechanism through which to ‘positively help the individual confront the anxiety provoking experiences’. The result was a set of defensiveness techniques including the splitting up of the nurse-patient relationship. A more recent research report (Hillman et al 2013) also report ‘defensive practice’ resulting in an ‘us and them’ subject position regarding their patients as nurses felt the pressures of litigation, complaints and the pressing need to meet the managerial requirements of the organisation.
Melia (1984) outlined two competing ‘segments’ – the ‘educational’, focusing on learning, and the ‘service’ which focused on ‘getting the work done’. In learning to ‘fit in’ students experienced a transient approach to nursing implicitly supporting a lack of commitment to nursing as an occupation. This is mirrored in a 2010 study of Norwegian students in which it is argued:
“While clinical practice often has focus on practical problem-solving and procedures, the college tends to focus on abstract theory. Both of these promote the privatisation and neglect of the students’ experience of care. The paper concludes with a call for teaching and learning strategies targeting the use of nursing students’ personal experience of care”. (p73 Solvoli and Heggen 2010).
So, no ‘golden age’ then or now.
In the 2013 ‘Too posh’ document, three commentators pointed out the critical place that clinical practice experiences have which implicitly build upon Menzies Lyth and Kath Melia. Professor David Sines argued that there needs to be:
1. dynamic placement opportunities for students that expose and challenge them to confront the complexity of health and social care, within, between and across clinical care pathways, supported by a curriculum that is ‘wrapped around the patient’s/user’s real experience and journey’;
2. robust, enhanced and effective mentorship and preceptorship partnerships with our Trusts;
These 2 ambitions will not be achieved in care environments where there is poor skill mix; care given by care assistants who may be poorly supervised and trained; poor staff-patient ratios and minimal professional support and development. Sines goes on to argue:
“Above all our next generation workforce requires access to expert mentorship and role models to nurture and inculcate excellence in practice and resilience in attitude to deliver optimal standards of care at all times, turning each patient encounter into a learning opportunity that leads to sustainable excellence” (p15).
Again this is a key issue: ‘Access to expert mentors’. Far too many students report the lack of both access and the quality of support in this area. Therefore this may sadly, in the current context, be too idealistic. This might be born out by Bradbury Jones et al (2011) who reported that not all students have a positive experience:
“Unfortunately there were many examples of disregard and disrespect of students as learners. Lack of encouragement and responsibility were significant issues and this had a negative impact on students’ knowledge and confidence. These findings are consistent with nursing literature in terms of lack of support and encouragement and specifically, lack of interest in learners (Lindop, 1999). The findings also mirror those of Levett-Jones and Lathlean (2008), who reported that while a number of students in their study had positive placements, too many had experiences where their learning was not optimised and their competence and confidence were negatively affected. Like the students in this study, Levett-Jones et al. (2009) found that some mentors seemed to disregard students’ feelings and made little attempt to hide their impatience and frustration” (p371).
Maura Buchanan also focuses attention on the clinical environment:
“ I would argue that the main responsibility for failing standards lies not with nurse education, rather, with the clinical practice environment for which employers must take blame” (p17).
Jenny Aston also points to deficiencies in the clinical environment:
“With university based training (sic), considerable responsibility is left with the placement mentor to ensure that students have the necessary hands-on nursing skills. Many students have minimal one-to-one learning from their clinical mentors,who are busy with their own responsibilities, and have little or no protected time to teach the essential skills…University lecturers rarely have the time to visit, let alone work, in the clinical areas”. (p21)
The responsibility for safe compassionate care rests with Trust boards. NHS management has taken its collective eye off the ball and is often ill equipped to know if poor care is being given. Universities cannot do the work for Trust boards. Any call for a return to apprenticeship training within NHS trusts must address this fundamental issue. In far too many cases there are insufficient governance practices in place to ensure care standards are upheld. Aston argued:
“There is a need for governance measures to be in place to ensure that care is of a high standard as there will always be a conflict between cost and quality. Board level
decisions need to be based on a good understanding of how care can best be delivered and measured so on the ground clinicians need to be informing high level decision makers. Great care needs to be taken to measure the right things and not just numbers; otherwise real improvements will not be demonstrated. An experienced pair of nursing eyes and ears can identify good and bad care in a way that complex audits or form filling may fail to achieve”.
Roy Lilley has often stated: ‘Fund the front line. Make it fun to work there, that way you will make Francis history”. Nurses and nursing students have been criticised as lacking in compassion. No doubt this is true for some nurses. However, it is the lack of governance and poor clinical environments that both grows uncaring attitudes and fails to weed them out. Trust Boards through excellent management must implement strategies that ensure the front line is properly supported and developed.
When only 1 nurse provides poor care, that is their personal trouble….when we have had a catalogue of reports into poor care, that is a public issue and we should not find the solution in the situation of any one nurse. We must look into the economic and political nature of NHS Trusts and of society to move beyond criticisms of individual nurses and their personal failings.
Beer, G. ed. (2013) Too posh to Wash. 2020.org Too Posh to Wash?
Bradbury Jones, C., Sambrook, S., and Irvine, F. (2011) Empowerment and being valued: A phenomenological study of nursing student’s experiences of clinical practice. Nurse Education Today. 31 p368-372
Hillman, A., Tadd, W., Calnan, S., Calnan, M., Bayer, A., and Read, S. (2013) Risk, Governance and the experience of Care. Sociology of Health and Illness. doi: 10.1111/1467-9566.12017 pp1-17
Levett-Jones, T., Lathlean, J. (2008) Belongingness: a prerequisite for nursing students’ clinical learning Nurse Education in Practice, 8 pp. 103–111
Levett-Jones, t., Lathlean, J., Higgins, I., and McMillan, M. (2009)
Staff-student relationships and their impact on nursing students’ belongingness and learning Journal of Advanced Nursing, 65 (2) pp. 316–324
Lindop, E, (1999) A comparative study of stress between pre- and post-Project 2000 students Journal of Advanced Nursing, 29 (4), pp. 967–973
Menzies Lyth, I. (1960) The functioning of social systems as a defence against anxiety. Human Relations. 13 (2) 95-121
Melia, K. (1987) Working and Learning: The Occupational Socialisation of student nurses. Tavistock press. London.
Solvoli, B., and Heggen, K. (2010) Teaching and Learning Care – exploring nursing students’ clinical practice. Nurse education Today. 30 (1) p73-77
Willis Commission (2012) Quality with compassion: the future of nursing education. http://www.williscommission.org.uk/
Wright Mills, C. (1959) The Sociological Imagination. Oxford University Press. Oxford.