Tag: Nursing

Developing the Concept of Sustainability in Nursing

“NOTICE: this is the author’s version of a work that has been submitted for publication in Nursing Philopsohy. If accepted, changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication.


Developing the concept of sustainability in nursing.




Sustainability, and the related concept of climate change, is an emerging domain within nursing and nurse education.  Climate change has been posited as a serious global health threat requiring action by health professionals and action at international level. Anåker & Elf undertook a concept analysis of sustainability in nursing based on Walker and Avant’s framework. Their main conclusions seem to be that while defining attributes and cases can be established, there is not enough research into sustainability in the nursing literature. This paper seeks to develop their argument to argue that sustainability in nursing can be better understood by accessing non nursing and grey literature and, for example, the literature in the developing web based ‘paraversity’. Without this understanding, and application in nursing scholarship, nurses will have a rather narrow understanding of sustainability and its suggested links with social and health inequalities and the dynamics underpinning unsustainable neoliberalist political economy. This understanding is based on the social and political determinants of health approach  and the emerging domain of planetary health.  However, this is a major challenge as it requires a critical reflection on what counts as nursing knowledge, a reflection which might reject this as irrelevant to much of nursing practice.




Sustainability, and the related concept climate change, is an emerging domain within nursing (Adlong & Dietsch, 2015; Allen, 2015; Aronsson, 2013; Goodman, 2011; Hunt, 2006; Polivka, Chaudry & Mac Crawford, 2012; Sattler, 2011) and nursing education (Goodman, 2008; Goodman, 2011; Goodman & East, 2013; Goodman & Richardson, 2009; Johnston et al., 2005; Richardson et al., 2013). Climate change has been posited as a serious health threat (Costello, Grant & Horton, 2008; IPCC, 2014; McMichael, Montgomery & Costello, 2012)  requiring action by health professionals (Costello et al., 2011; Gulland, 2008; Harding, 2014; Patton, 2008; Reale, 2009; Thomas, 2014) and action at international level (Durban Declaration on Climate and Health, 2011; WHO (2016) . The status of climate change as health threat has however been contested (Goklany, 2009a; Goklany, 2009b; Goklany, 2012; Goodman, 2014), but it remains an important determinant of health (Barton & Grant, 2006; Griffiths, 2009). In this context, Anåker & Elf (2014) undertook a concept analysis (Walker & Avant, 1982)  of sustainability in nursing. This paper seeks to develop their argument to argue that sustainability in nursing can be better understood by accessing non nursing literature, to address the socio-political context in more depth. This should include going beyond accepted peer reviewed nursing journals and include literature such as that written by Wendell Berry (Berry, 1995) who writes eloquently on human health and our relationship to the natural environment.  There is also a growing body of work online and of an academic standard to qualify for what might be called the ‘Paraversity’ (Goodman, 2015a; Rolfe, 2013). Without this understanding, and application in nursing scholarship, nurses will have a rather narrow understanding of sustainability. There is a need to link social and health inequalities (Dorling, 2013; Marmot, 2015) and the dynamics underpinning unsustainable neoliberalist political economy (Harvey, 2005; Harvey, 2014; Sayer, 2015) with the concept of sustainability. Climate change is just one aspect, albeit a very important aspect, of that linkage. This understanding is based on the social (Davidson, 2015; Raphael, 2004; WHO, 2013) political (Ottersen, Frenk & Horton, 2011) and ecological (Goodman, 2014; Goodman, 2015b; Lang & Rayner, 2012; Lang & Rayner, 2015; Rayner & Lang, 2012) determinants of health (Barton & Grant, 2006).  However, this is a major challenge as it requires a critical reflection on what counts as nursing knowledge, a reflection which might reject this as irrelevant to much of nursing practice. Before addressing the definition of sustainability in nursing, the socio-political ‘pattern of knowing’ will be outlined to form the justification for the ensuing discussion.


The fifth ‘Pattern of knowing’ in Nursing

Jill White (White, 1995) added a fifth pattern of knowing in nursing to Barbara Carper’s four (Carper, 1978): the ‘Socio-Political’. White argued the other four patterns provided answers to the ‘who, how and the what’ of nursing practice but not the ‘wherein’, the context. This, White argued, is the pattern of knowing essential to an understanding of all the other four. Socio-political knowing that is gained from a fuller understanding of the ‘sustainability literature’, might lift the ‘gaze’ from introspective nurse patient relationships at the bedside and requires the situating of that relationship within the wider socio-political context. This may result in challenging the taken for granted assumptions about practice, health, the profession and wider health policy. To that could be added the raising of questions about political economy and engaging in philosophical enquiry about such concepts such as ‘non duality’ (Loy, 1988), a concept Wendell Berry implies in his essay ‘health is membership’ (Berry, 1995).

White quoted Chopoorian who suggested:  “nursing ideas lack an archaeology of the social, political and economic worlds that influence both client states and nursing roles’ (White 1995 p84). This ‘archaeology of ideas’ still seems relatively poorly uncovered. Davies argued that ‘some of our concepts are missing’ in a critique of the Sociology of Health and Illness (Davies, 2003).  By that is meant that there had been a lack of a ‘sociology’ of organizations in the sociology of health and illness, a sociology which is able to reveal concepts such as discourses of managerialism (Gilbert, 2005; Traynor, 1996; Traynor, 1999; Traynor, Boland & Buus, 2010), or to reveal patterns of power and accountability for policy and its consequences (Freudenberg, 2014; Scambler, 2012; Schrecker & Bambra, 2015). Davies argued that

“sociology needed to take seriously the politics of NHS modernisation” (p183)

It is suggested here that many nurses also don’t have such a set of critical concepts to give them a more critical discourse upon which to base critical action or ‘praxis’ (Cox & Nilsen, 2014). There are a few papers addressing political activism in nursing, providing critical theories and concepts (Antrobus, Masterson & Bailey, 2004; Hewison, 1994; Phillips, 2012; Racine, 2009; Shariff, 2014) and other papers which discuss politics and nursing (Davies, 2004; Masterson & Maslin-Prothero, 1999; Salmon, 2012; Traynor, 2013).  These works suggest an interest in the interplay of the socio-political context and nursing practice and provide some evidence of relevance of this ‘pattern of knowing’.  White argued that nurses must “explore and expose alternative constructions of health and health care, find means of enabling all concerned to have a voice in care provision and develop processes of shared governance for the future” (p85). Exploring sustainability, climate change and health assists in that work. Indeed a focus on global governance for health in the context of climate change and environmental challenges is a key theme of recent reports  (Ottersen, Dasgupta & Blouin, 2014; Ottersen, Frenk & Horton, 2011) in non-nursing literature. This leads us onto consider how nurses are to understand what sustainability means.


Defining Sustainability in Nursing


Anåker & Elf (2014) argue that the “term is not clearly defined and is poorly researched in nursing” (p382). This applies not only in nursing.  Sustainability has diverse and contested meanings in many disciplines (Thompson, 2011; Williams & Millington, 2004). The quest to tie down the concept is possibly futile, as Anåker and Elf themselves suggest that: “a concept analysis is never a finished product” (p388). They provide a definition which is a helpful contribution to the discussion, and their model and contrary case illustrate for clinical nurses the value of trying to understand sustainability in practice. Throughout the paper they provide attributes and definitions from various sources and refer to, but do not foreground, social and health inequalities arising from wider determinants of health including political economy, which also underpins understandings of sustainability and climate change (Goodman & Richardson, 2009; Sayer, 2015).

The defining attributes identified in Anaker and Elf’s concept analysis were:  ecology, environment, the future, globalism, holism and maintenance. The attribute ‘globalism’ indicates that they are getting close to discussing and emphasising political economy underpinning such issues as climate change, ocean acidification and soil erosion which are three of the nine planetary boundaries which, it is argued, delineate a ‘safe operating space for humanity’ (Rockstrom et al., 2009; Steffen et al., 2015) . Nonetheless, the analysis misses something important, i.e. the neoliberal (Freudenberg, 2014; Harvey, 2005) and environmental, socio-political context of health (Barton & Grant, 2006; Ottersen, Frenk & Horton, 2011; Sayer, 2015; Scambler, 2012; WHO 2015) characterised by social and health inequalities (Dorling, 2013). This is the link between capitalism, climate change and sustainability (Goodman, 2014; Griffiths, 2009; Klein, 2014; Sayer, 2015). Various writers (Hamilton, 2010; Jackson, 2009; Marshall, 2014; Sayer, 2015; Urry, 2011) suggest or imply, that it is our political orientations (Douglas & Wildavsky, 1992), moral intuitions (Haidt, 2012) and our social and economic relationship with carbon which are foundations upon which we as communities and individuals assess environmental issues and our reactions to them.

Urry particularly on this point, (2011) coins the term, ‘high carbon economy-society’ to describe capitalism. He argues that the starting point for an analysis of why society engages in particular practices and habits is the observation that energy is the base commodity upon which all other commodities exist. Thus, community behaviours are implicitly locked into high carbon systems that are taken for granted aspects of our lifeworld. Urry suggests that much of social science has been carbon blind and has analysed social practices without regard to the resource base and energy production that we now know are crucial in forming particular social practices. It is these social practices that provide the structure within which our agency operates.

most of the time people do not behave as individually rational separate economic consumers maximising their individual utility from the basket of goods and services they purchase and use given fixed unchanging preferences…(we are) creatures of social routine and habit…fashion and fad…(we are) locked into and reproduce different social practices and institutions, including families, households, social classes, genders, work groups, schools, ethnicities, generations, nations…. (Urry 2011 p4).


These social practices arise out of our ‘lifeworld’ (Husserl 1936, Habermas 1981), i.e. our internal subjective viewpoints as well as the external viewpoints of the social and political ‘system’.  A high carbon economy society thus provides the backdrop for values, assumptions and social practices that are taken for granted in everyday life. Defining sustainability therefore requires acknowledgment of such lifeworlds and the socio-political systems in which they ‘operate’.


Nursing, sustainability and acontextual Concept Analysis?


The wider body of literature, including that in the social and political sciences and philosophy, may give nurses tools and concepts to further develop their understanding of sustainability and its relationship to human health. Importantly this could include an understanding of the political economy of capitalism (Harvey, 2011) and its link with growth, climate change and sustainability (Hamilton, 2003; Jackson, 2009; Johnson, Simms & Chowla, 2010; Sayer, 2015). Without this understanding, and application in nursing scholarship, nurses may miss the arguments linking the growth dynamics underpinning the neoliberalist capitalist political economy (Chomsky, 1997; Harvey, 2005; Sayer, 2015), climate change (Klein, 2014; Sayer, 2015) and unsustainable lifestyles (Hamilton, 2010). This sits within the social and political determinants of health approach (Barton & Grant, 2006; Davidson, 2015; Ottersen, Frenk & Horton, 2011; Scambler, 2012) and the emerging domain of planetary health (Lang & Rayner, 2012; Lang & Rayner, 2015).  This paper argues that to fully develop the concept in nursing, an analysis or at the least an understanding, of the political economy of neoliberal capitalism could be a component of nurses’ understanding of sustainability and health. This is because political economy relates to both health and social inequalities (Dorling, 2013; Dorling, 2014; Marmot, 2015; Schrecker & Bambra, 2015; Stiglitz, 2012; Wilkinson, 2005; Wilkinson & Pickett, 2009)  and to issues around sustainability and climate change. However, this is a major challenge as it requires a critical reflection on what counts as nursing knowledge (White, 1995), a reflection which might reject this as irrelevant to much of nursing practice.


Anåker & Elf’s (2014) inference that nursing misses foregrounding political economy and society might be a result of the method employed to search the literature, as well as their acknowledged lack of discussion in the nursing literature of political economy. Of course there might be very little reason currently for nursing literature to discuss political economy, based as it is on knowledge (biosciences, biomedicine) that may well be largely antithetical to critical social and political science. Adult nurses in particular might face a real challenge in accepting this idea in practice as Ion and Lauder argue:


“For very good reason, adult nursing remains committed to a biomedical vision of illness which, while cognisant of the importance of a holism, is tied to a physical approach to care” (Ion & Lauder, 2015).


In addition, Walker and Avant’s method was originally published (1982) before the development of academic blogs and websites such as academia.edu and therefore may not be explicit in its direction to search beyond accepted channels. This emerging literature, which may contribute to the construction of the ‘paraversity’ (Goodman 2014, Rolfe 2014), will therefore be missed as source of information and discussion on topics such as linking sustainability, health, climate change and capitalism.


There are several key papers discussing the link between human health, political economy and the environment. Goodman and Richardson (2009) explicitly link Sustainability, Climate Change and Health conceptualizing them as three sides of a triad. To fully understand one requires an understanding of the other two. The three, in this conception, are indivisible. Further, the link involves political economy and socio-economic behavior as crucial underpinnings for climate change and sustainability issues. Barton and Grant’s (2006) health map discusses key determinants for health including Biodiversity, Global Ecosystems and Climate change. Each one of those of course involves human activity and disruption to create what some are calling a new geological era, the ‘Anthropocene’ (Zalasiewicz et al., 2010). Lang and Rayner (2012) discuss the concept of ‘Ecological Public Health’, while the Canadian Public Health Association (2015) has just published its own report on ‘Global Change and Public Health: Addressing the ecological determinants of health’ which on page 1 argues:

“…changes in the earth’s ecological systems are driven principally by our social and economic systems, and by the collective values and institutions that support them”.

This echoes the World Health Organisation’s definition of the social determinants of health which explicitly mentions distributions of resources, money and power (WHO 2015). The report does not name, or analyses, in any more depth what that economic system is, as it seems to take for granted that it is capitalism. Ottersen et al emphasize the political determinants of health (Ottersen, Dasgupta & Blouin, 2014) which, alongside the WHO’s (2008) social determinants of health approach, acknowledges the role of powerful global actors and the lack of global governance for health. Health equity and social determinants are now a crucial component of the post 2015 sustainable development goals (WHO 2015).

For example, powerful global actors, i.e. the Fossil Fuel Industry, may be acting in a way to either downplay the risks to human health from rising atmospheric carbon dioxide, or engaged in protecting their assets’ (coal oil and gas) value for the short term over and above longer term risks to climate. Exxon Mobil have argued that world climate policies are highly unlikely to stop the production and selling of fossil fuels (Exxon Mobil shrugs off climate change risk to profit – BBC News, 2014) while Shell have been accused (Macalister, 2015) of accepting a 4 degree rise in global mean temperatures. This is in the context of a reported $5 trillion annual subsidy in fossil fuel subsidies (Coady et al., 2015)  while the Bank of England considers a ‘carbon bubble’ (Carrington, 2014)  i.e. the drop in value of assets if fossil fuels are kept in the ground through the imposition of any global governance regimes to curb carbon emissions. This is an aspect of the political economy of capitalism that must be understood as a driver underpinning human health. At the time of writing, world leaders and delegates are meeting in Paris for COP 21. At this meeting there will be another meeting of the The Sustainable Innovation Forum (SIF15) which is a business focused event held during the annual Conference of Parties (COP). The two day Forum will convene  participants from business, Government, finance, the United nations, Non-governmental organisations, and civil society to “create an unparalleled opportunity to bolster business innovation and bring scale to the emerging green economy” (COP21 Paris 2015). This forum operates within the paradigm of capitalism rather than seeking radical reform. However, it illustrates the complexity of players dealing with sustainability issues.


Scambler (2012) outlines ‘The Greedy Bastards Hypothesis’ to describe how the Capitalist Class Executive can ‘command’ the Political Power Elite to enact policies in their favour, with the unintended consequences of exacerbating health inequalities. Evidence that corporate activities impacts on political decision making is provided by the delays to air pollution standards, Euro 6 (Archer, 2015; Neslen, 2015).  Volkswagen’s use of software to cheat emissions testing in the United States (Topham, 2015) indicates the lengths corporates will go (Freudenberg, 2014; Oreskes & Conway, 2011) to avoid externality costs resulting in the externality of for example, increased air pollution. Therefore any concept of sustainability in nursing that does not understand political economy misses something important in understanding both the concept of sustainability and of health.


Anaker and Elf’s definition of sustainability:

“…a core of knowledge in which ecology, global and holistic comprise the foundation. The use of the concept of sustainability includes environmental considerations at all levels. The implementation of sustainability will contribute to a development that maintains an environment that does not harm current and future generation’s opportunities for good health”. In this it echoes the Brundtland commission’s definition of sustainable development (WCED1987) which has been critiqued for being uncritical of business and growth based capitalism (Sinclair 2009).


This definition is a good start but requires development. Nurses, particular nursing scholars interested in health and public health, need to consider the argument already suggested around the dynamics of capitalism as a major driver for both carbon emissions and unsustainable practices. It is perfectly possible to begin the study of sustainability and environmental health within taken for granted paradigms, but what is required is a cultural critique of the values and systems that support environmental damage (Martusewicz 2014) and a better understanding how the economy and sustainability issues such as climate change, interact (Better Growth, Better Climate, 2015). Nurses, if they stick to nursing journals and literature, will not find a large amount of material that discusses this. For example the Royal Society of Arts has a wealth of papers, presentations and works streams addressing climate change (Hahnel, 2015; Rowson, 2015)  which address causes, behaviour changes, political economy and culture change.




Anåker & Elf (2014) argue that there is a need for theoretical and empirical studies of sustainability in Nursing. This could include accessing literature unknown to most nurses.  Writers such as Aldo Leopold, Wendell Berry, Paul Hawken, Mike Hulme, John Urry all provide insights into human wellbeing, health and the social context. Related concepts include ecojustice education, education for sustainability, dualism, anthropocentrism, anthropocene, neoliberalism, modernity and capitalism. A problem for nursing scholars is that these related concepts are not readily seen as relevant to nursing and thus there may be a reticence of nursing journals to publish them, and a reticence in nurse education to discuss them. There may be a need to resort to both non nursing peer reviewed journals but also to web based materials open to all. Anaker and Elf acknowledge in their limitations (p387) ‘the lack of research literature available for review in which sustainability was the major topic and in which sustainability was not linked to other concepts’. This paper goes further in trying to make those wider links for nurses. A problem however for nurses, is the sheer scale of literature and concepts that are involved. The task for nursing scholars is to consider just what is feasible, useful and relevant as part of their scholarly development and curriculum work.



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Rockstrom, J., Steffen, W., Noone, K., Persson, A., Chapin, F. S., III, Lambin, E. F., Lenton, T. M., Scheffer, M., Folke, C., Schellnhuber, H. J., Nykvist, B., de Wit, C. A., Hughes, T., van der Leeuw, S., Rodhe, H., Sorlin, S., Snyder, P. K., Costanza, R., Svedin, U., Falkenmark, M., Karlberg, L., Corell, R. W., Fabry, V. J., Hansen, J., Walker, B., Liverman, D., Richardson, K., Crutzen, P. & Foley, J. A. (2009) ‘A safe operating space for humanity: identifying and quantifying planetary boundaries that must not be transgressed could help prevent human activities from causing unacceptable environmental change, argue Johan Rockstrom and colleagues’. Nature, 461 (7263). pp 472.


Rolfe, G. (2013) The University in Dissent; Scholarship in the Corporate University. London: Routledge.


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On Climate Change

On Climate change

The health effects of climate change

The role of the nurse in addressing the health effects of climate change

“To mobilise people this has to be an emotional issue. It has to have the immediacy and salience. A distant, abstract, and disputed threat just doesn’t have the necessary characteristics for seriously mobilising public opinion.” Daniel Kahneman in Marshall (2014 p57). He stated “I am deeply pessimistic. I really see no path to success on climate change”.


Climate change needs:


  • Salience – qualities that mark it out as prominent and demanding attention, something concrete, immediate and indisputable. Climate change is none of these things for the mass of the population.
  • Acceptance of short term costs to mitigate uncertain long term losses. This is something we are not prone to do.
  • Certain and uncontested information. As long as billions of $ in the US and the UK support denial and the vested interests of the fossil fuel lobby in media this remains at the level of popular culture, and in politics, uncertain and disputed. Those with the power and finances to affect change do not want to do so as it is perceived to threaten their base values.


People, however:

  • Are more averse to losses than gains. If changing to a low carbon lifestyle means giving up the car, air travel, eating red meat, buying fewer consumer goods then the longer term gains of the health co-benefits will not be able to compensate for their immediate short term losses.
  • Are more sensitive to short term costs than long term costs, so again giving up the car is a more sensitive issue, and more salient, than flood damage 30 years from now.
  • Will privilege certainty over uncertainty. Scientists do not talk the language of certainty, and this is ruthlessly exploited by those with a vested interest in the status quo.

However, George Marshall argues that people will willingly shoulder a burden  – even one that requires short term sacrifice against uncertain long term threats – provided they share a common purpose and are rewarded with a greater sense of social belonging.

This provides a glimmer of hope especially for the  nursing commitment to climate change. Nurses often come into the profession with a purpose, a ‘shared humanitarian ethos of care’ rather than an extrinsic motivation based on money and consumer durables. How we create a greater sense of social belonging requires that we overty combat the atomistic, fragmented and individualistic culture based on the idea that “there is no such thing as society“.


Marshall G (2014) Don’t even think about it: Why our brains are wired to ignore climate change. Bloosmbury. New York

How to do thinking in Nursing?

The picture above is the colorado river cutting its way through the rocks on its way down to the Grand Canyon.

Nursing and ‘On Intellectual Craftsmanship’ (C. Wright Mills 1959)

‘Doing’ professional registered nursing involves ‘hands on’ practical skills, but it also involves ‘thinking’. If there is no thinking then nursing has been reduced to a ‘procedure’, a sequence of ‘hands on’ practical skills which requires training rather than higher education and which can then be undertaken by care assistants. The thinking required is not just the recollection of facts to be applied to a patient situation. For example knowing what a drug does, what the correct dose is, and whether it is right for the patient, is a recollection of factual information. The mere collection of thousands of ‘facts’ in your head to be applied to patient care, reduces registered nursing, again, to a procedure, albeit complicated by the sheer number of facts. In a rapidly changing world of demographic changes, new technological developments, environmental damages, shifting health care delivery systems, geo-political conflicts and global socio-economic challenges, what is required is critical thinking supported by scholarship. The professional nurse with a higher education preparation will, or ought to be, engaged in critical thinking to move beyond merely recalling facts as we cannot insulate ourselves from the social and political contexts in which we work.

How do we do this? Sociologist C Wright Mills in 1959 clearly called for scholarship and criticised some sociologists at that time for not doing this. In the appendix to ‘The Sociological Imagination’ Wright Mills outlines his view on ‘doing’ social science in which he suggests that ‘Scholarship’ (“scholarship is writing”) is more important for the social, as opposed to the ‘natural’ scientist, than empirical research. If nursing is as much a social science based practice discipline as one that is also rooted in the biomedical sciences, then this argument applies.

Wright Mills referred to empirical science as the “mere sorting out of facts and disagreements about facts”. I would argue that this equally applies to professional nursing (Goodman 2011). Student nurses study evidence based practice and the application of research to practice. A good deal of this is factual information based upon empirical research . Students will, however, we required to critique this research. This will involve studying ‘rules of method’, i.e. how do we ‘do’ research, but arguments on this, e.g. is an interview better than a survey to help us answer this research question, are just so much navel gazing which Wright Mills wished to avoid if he could possibly do so, as he argued:

“Now I do not like to do empirical work if I can possibly avoid it” (p205).

Wright Mills was clear on this. He argued that the task of social science and I would add professional nursing is thus to critically engage in the real world, joining the nurse’s personal experience and intellectual life through critical reflective reason as the

“advance guard in any field of learning” (p205).

Empirical ResearchA central concept in modern science and the scientific method is that all evidence must be empirical, or empirically based, that is, dependent on evidence that is observable by the senses. The term refers to the use of working hypotheses that are testable using observation or experiment. In this sense of the word, scientific statements are subject to, and derived from, our experiences or observations. Crudely, this means we need to be able to measure things, we need to be able to see, touch, hear…..


Wright Mills in arguing for craftsmanship in intellectual life implicitly acknowledges in the ‘Sociological Imagination’, the need to go beyond simple empirical knowledge in forming policy action when he asks social scientists in their political and intellectual tasks to clarify the contemporary causes of uneasiness and indifference (p13) to personal troubles and public issues.

The personal trouble of lying in soiled sheets in a hospital ward has to be linked to the public issue of the provision of care for older people in acute hospitals. This issue and our indifference to it, or our unease with it, has to be critically examined to seek answers beyond simply blaming uncaring individuals.

The social scientist is not to merely describe the contemporary elements of social life but to engage with it. The nursing ‘scientist’ is not to merely describe contemporary elements of patients’ experiences, e.g. abusive care, but to engage with it. Professional nurses charged with delivering care are thus asked to engage in critically understanding the social, political and economic structures in which care occurs.


Wright Mills uses the word ‘craftsmanship’. The use of the word ‘craft’ appears here to differentiate the activity from that of mere mastery of elaborate discussions about research method and which would quickly make one “impatient and weary” (p195). A craft suggests development of skill by diligent constant practice, honing one’s technique by reference to finished products and products in the process of being created to evaluate their flaws and strengths and then adjust accordingly. This is reflexive practice in that the work as it continues is being constantly worked and reworked as required. It suggests leaps of imagination and intuitive thinking and practice in the creation of a project. It calls for a departure from strict adherence to a rigid structure of routines, methods and frameworks. It also suggests a measure of artistry in thinking. In other words a potter ‘crafts’ his pot, as the clay spins there is a constant feedback to the craftsmanship of what is happening, he or she constantly adjusts the application of skill to fashion what they want. Some of this is under conscious control, some of it is unconscious based on years of experience and input. Likewise, thinking and scholarship can be a craft in this manner. The end product is not a pot but a theory, an argument, a series of questions, an hypothesis. In fact there may not be an end product as thinking may be continuous.

The scholarly craftsman is his or her work as their craft develops alongside who they are. Scholarly craftsmanship then is a state of being not only doing:

“Scholarship is a choice of how to live as well as a choice of career” (p196).

When Wright Mills wrote that:

“admirable thinkers…do not split their work from their lives” (p195)

…he preconceives notions of lifelong learning that are to follow.

Nursing practice if it were to take this concept on board may then have to consider a break away from a wage based employee model where a nurse works for 37.5 hours per week to a salaried professional/intellectual model whereupon the nurse would continue to critically reflect on issues pertinent to speciality and patient group outside of NHS contracted hours. Given the current context of the NHS and clinical practice this seems highly unlikely for clinically based nurses. But if not them, who? If not now, when? If not here, where?

To undertake this craft he asks students and social scientists to keep a journal to enable the development of the intellectual life, of the craftsmanship of social science. This should consist of ideas, personal notes, excerpts from books, bibliographical items and outlines of projects. He suggests that journals should record ‘fringe thoughts’, snatches of conversation and even dreams. This will also include the taking of copious notes from books and this needs developing into a habit.

Since Wright Mills outlined notes on journal keeping there has been the explosion onto the scene of information technologies, elearning and web 2.0. These are now new tools that were unavailable to Wright Mills. However the essential nature of scholarly activity should not be lost in any infatuation with new technologies, rather these gateway technologies could facilitate critical enquiry and journal keeping.

Wright Mills’ work thus calls for the development of scholarship as a core intellectual activity. However, critical scholarship within nursing is under threat both in practice and in Universities, skewed as it is towards empirical enquiries and buckling under the weight of bureaucracy, managerialism and the demands of the corporate University. There is an urgent need to rediscover it if we are to address the complex questions and serious issues of our age such as inequalities in health, care of frail older people, health service funding, diabetes, obesity and cardiovascular disease, depression, anxiety, the social and political determinants of health and climate change. Nurses can choose to engage with this agenda or not.





The personal is political; care in an age of spectacle.

Are we really surprised that the BBC’s  Panorama has again uncovered  poor quality care and abuse in a home for older people?

We know the roots of this, and I have previously argued that this is a political game. This is also personal because, and this point has been made many times  before, I will be old one day and may well require care. Therefore I do not want to be treated like sh*t as a resident on the Panorama  film stated. It happens because the care sector is undervalued, invisible, ‘women’s work’ and it is thought by some  that it can be done by those with little training, poor supervision, risible pay, poor patient ratios, no professional development and inadequate management.

Individuals will of course be blamed and sacked citing ‘accountability’ as if it is the holy grail of quality care and patient safety.

What to do? The first is to recognise that this personal trouble is a political issue and nurses are front line staff in the trenches. In the UK for far too long nurses have been reluctant to use union power to address these fundamental issues. Yet, just when we need it, union membership across all employment sectors have dropped as workforces became more docile in the face of deregulated labour markets. Faced with the ‘flexibility’ requirements demanded by employers, resulting in the growth of zero hours contracts, part time working, minimum wages as targets rather than base lines, workers have become more pliable generally. Nursing, being a gendered occupation with its emphasis on self sacrifice and care, has historically shied away from exercising any worker power while simultaneously picking up the crumbs from the medics table (doing their ‘skilled’ tasks for nowhere near the pay) and now bowing to the control of their work as dictated by management.

In California, in the US, nurses are joining Unions and have a staffing ratio law of 5:1 for med/surg, 2:1 for ICU, and Psych 6:1 meaning five patients with 1 nurse. CA AB394 came about by the CA Nurses Association to implement their RN Staffing Ratio Law. William Whetstone (Professor of Nursing California State University)  states “Staff nurses were sick and tired of being abused, putting up with crappy workloads, incompetent nurse administrators and managers, and on and on. I can remember when I did staff nursing dealing with a patient load of 10 to 12 patients with no thought to their acuity. As a result, CA became the first state through the effort of the CA Nurses Association to establish RN-to-patient ratios. The law was successfully implemented January 1, 2004”.

Is this an increasing phenomenon? Are we finally seeing a backlash against the dominant political hegemony that does not want to pay for care? We can study this until forever, but that fact remains – care costs. It costs a lot, requires skill and adequate ratios.

In California it seems nurses have had enough, got organised and agitated for change. They have looked beyond the representations of nurses as caring angels and seen themselves as the exploited.  They have plucked the imaginary flowers from their chains and acted.

Consumer capitalism would not want this happen because care is seen, in this context, as a cost to be born not by society but by individuals and families. Consumer capitalism instead wants to fill our heads with distractions and representations using the ‘spectacle’.

News and other media constantly feed us representations of the world that actually do not exist; they are constructed for news and or as entertainment. Panorama falls into that trap because it represents poor care in a particular way and is unable to drill down to the root causes. The TV itself is a medium of the representation of actuality and can lull us in to classifying the poor care we see as almost entertainment; the lines between truth and  fantasy become blurred.


“In societies where modern conditions of production prevail, life is presented as an immense accumulation of spectacles. Everything that was directly lived has receded into a representation” (Debord 1967).

Consumer capitalism has ripped the citizen role from the heart of nursing and replaced it with consumerism in which we are presented daily with ‘the spectacle’ – representations of reality that are without form or substance but which service to make sacred the profane. The spectacle specifically aimed at women include the array of women’s magazines which preach that you can never too thin or that your breasts require surgical enhancement; thus are we distracted about what is truly real by a false representation, within care employment contexts that are precarious, undervalued and invisible. Feminists know this, critical theorists know this, those with a sociological imagination know this, many women actually feel the cognitive dissonace that this engenders. In California,  nurses have acted as citizens, able to see pass the distractions for long enough to see exploitation as it really is. In the UK those nurses who can see the reality, need to the support to take charge of care in this country.

Ordinary citizens need to organise their frustrations and anger over health and social care and cohere into a viable opposition. Unfortunately UKIP are currently presenting another false representation with the spectacle of Nigel Farage presented as an ‘ordinary bloke’ that nearly 30% of the electorate are falling for.

We saw a spectacle of poor care again last night, lets not allow it to become entertainment for its shock value, lets instead urge action by all of us to provide the care older people deserve.


Nurse -patient ratios – what is the evidence?

Peter Griffiths of Southampton University wrote on the researchgate site:

“…..this is an area with a massive literature. The positive association (between more nurses and better patient outcomes) has been demonstrated against a range of quality and safety measures – primarily safety. Linda Aiken is not the only researcher in the area but possibly the best known. 

Try : Kane, R.L., Shamliyan, T.A., Mueller, C., Duval, S., Wilt, T.J., 2007. The Association of Registered Nurse Staffing Levels and Patient Outcomes: Systematic Review and Meta-Analysis. Medical Care 45 (12), 1195-1204 1110.1097/MLR.1190b1013e3181468ca3181463.

…for a comprehensive if slightly dated overview of the safety literature.

Recent reports from the RN4CAST study show associations with other outcomes e.g.:

Ball, J.E., Murrells, T., Rafferty, A.M., Morrow, E., Griffiths, P., 2013. ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Quality & Safety.

Aiken, L.H., Sermeus, W., Van den Heede, K., Sloane, D.M., Busse, R., McKee, M., Bruyneel, L., Rafferty, A.M., Griffiths, P., Moreno-Casbas, M.T., Tishelman, C., Scott, A., Brzostek, T., Kinnunen, J., Schwendimann, R., Heinen, M., Zikos, D., Sjetne, I.S., Smith, H.L., Kutney-Lee, A., 2012. Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. British Medical Journal 344.

Aiken, L.H., Sloane, D.M., Bruyneel, L., Van den Heede, K., Sermeus, W., 2013. Nurses’ reports of working conditions and hospital quality of care in 12 countries in Europe. International Journal of Nursing Studies 50 (2), 143-153.

…although limited as they are all self report.

The translation of this to specific ratios is difficult – largely for the reasons highlighted above and the evidence on that policy is less clear cut. Try

McHugh, M.D., Brooks Carthon, M., Sloane, D.M., Wu, E., Kelly, L., Aiken, L.H., 2012. Impact of Nurse Staffing Mandates on Safety-Net Hospitals: Lessons from California. Milbank Quarterly 90 (1), 160-186.

For a favourable gloss.

Some of the limitations are covered in:

Griffiths, P., 2009. RN+RN=better care? What do we know about the association between the number of nurses and patient outcomes? International Journal of Nursing Studies 46 (10), 1289-1290.

…one issue that is very germane for many health sectors is the absence of medical staffing from this literature. See

Griffiths, P., Jones, S., Bottle, A., 2013. Is “failure to rescue” derived from administrative data in England a nurse sensitive patient safety indicator for surgical care? Observational study. International Journal of Nursing Studies 50 (2), 292.


I would add:

This question is rooted within a wider context – that of managerialist control of care environments (Traynor 1999, Lees 2013) in which efficiency, effectiveness and economy are to the fore. This approach can militate against the consideration of qualitative, non measurable, outcomes which make a real difference to patients’ experience (Tadd et al 2011, Dixon-Woods et al 2013, Hillman et al 2013). The reality is that many health and social care sectors, in the UK, are under such financial pressure and managerialist control,  that the quality of the care experience is squeezed. Given current narratives of austerity, female undervalued labour and ‘private = good public = bad’, UK society has accepted that for example long term care of older people, and mental health, have to fight their corner for government and personal funding. I suspect that funders (e.g. DoH and FTs) ignore evidence, in any case, of staff-patient ratios, viewing it as idealistic and costly. However, they will not frame it in this way – the response will be that ratios are a blunt tool and should not be set down in terms of basic minimums. While I think it is imperative that evidence comes forth on this topic, we might need to consider that the translational model of evidence to policy is flawed. In the context of climate science,  Pielke (2010) describes the actual relationship between public policy and scientific research as problematic; it is not a linear ‘evidence to policy’ model.  The translational model, or ‘knowledge translation’ (Kerr and Wood 2008), in which scientists come up with answers which are then put into practice by policy makers (Wynne 2010) is contextualised within political and ideological frameworks such as that of neoliberalism and its adjutant, managerialism.  Naively we may think that the job of scientists, and their allies, is to improve the process of knowledge translation so that policy makers, guided by clear evidence, can make the right decisions. Drugs policy research is another example of the failure of this model. In nursing, even if we had irrefutable evidence, there is no necessary link to this and health policy on nurse staffing. The UK’s NHS is a ‘highly politicized setting’ (Traynor 2013), staffing of wards is as much a political as an empirical question.

Dixon-Woods, M., Baker, R., Charles, K., et al (2013) Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Quality and Safety (published online) http://www.ncbi.nlm.nih.gov/pubmed/240195079th September 2013 accessed February 25th 2014
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. 35 (6) pp 939-955
Kerr, T., and Wood, E. (2008) Closing the gap between evidence and action: the need for knowledge translation in the field of drug policy. International Journal of Drug Policy 19 (3) pp 223-234
Lees, A., Meyer, E., and Rafferty, J. (2013) From Menzies Lyth to Munro: The problem of Manageralism. British Journal of Social Work. 43 (3) 542-558
Pielke, R. (2010) The Climate Fix. Basic Books. New York.
Tadd, W., Hillman, A., Calnan, S., Calnan, M., Bayer, T., and Read, S. (2011) Dignity in Practice: An exploration of the care of older adults in acute NHS Trusts. NIHR Service Delivery and Organisation Programme. Project 08/1819/218. NETSCC – SDO: Southampton
Traynor, M. (1999) Managerialism and Nursing: beyond profession and oppression. Routledge. London
Traynor, M. (2013) Nursing in Context. Policy, Politics, Profession. Palgrave Macmillan.
Wynne, B. (2010) Strange Weather, Again. Climate Science as political art. Theory Culture and Society 27 (2-3): 289-305

Nursing and the NHS – wtf is going on?

I cannot take credit for this, it is Roy Lilley, and although I was about to write about it,  I thought, nah, Roy has done it better: 


Talk to the DH and they will tell you there are more nurses than there are daffodils smiling in the spring sunshine.


An extra 2,400 hospital nurses have been hired since Francis and over 3,300 more nurses working on wards since May 2010.  The bit that is missing is; ‘more’ doesn’t mean ‘enough’ and enough doesn’t mean enough of the ‘right sort’.


The RCN says; The NHS has lost nearly 4,000 senior nursing posts since 2010.  The ‘missing’ nurses include ward sisters, community matrons and specialist nurses.  They’ve gone because they cost more; drop them and you save loadsamoney… quicker.


According to the latest data, November 2013; the NHS was short of 1,199 full time equivalent registered nurses compared with April 2010.  The RCN says; ‘… hidden within wider nursing workforce cuts is a significant loss and devaluation of skills and experience’… just under 4,000 FTE nursing staff working in senior positions.  Band 7 and 8 have been disproportionately targeted for workforce cuts.  It looks like nursing is being de-skilled. (Must look graph).


If the evidence of my in-box is to be believed nursing is not just being de-skilled, it is being denuded.  Time and time again I hear stories of nurse patient ratios of 9,10,11,12,even 18 and often quickly beefed up for the benefit of the CQC.


“Let each person tell the truth from their own experience.”  Florence Nightingale.


Funnily enough, I am writing this on a plane where the cabin-crew to passenger ratio is a matter of law.  I see no reason why the nurse to patient ratio shouldn’t be a matter of law.


The Chief Nurse doesn’t agree.  She’s faffing-about with her half-dozen C’s and ignores the risk that one nurse looking after a dozen or more vulnerable patients is a risk to the Six C’s.  She speaks, unthinking, with her master’s voice…  I hope she’s ready to explain the inevitable.. the next Mid-Staffs.


“The very first requirement in a hospital is that it should do the sick no harm.”  Flo Nightingale again.


There’s a wilful blindness to what’s going on; on the wards and at the ‘high-end’ of nursing; nurse specialists.  If the RCN is right (and this H&SCIC FoI confirms) it is a madness that their numbers are reducing.


Nurse Clinical Specialists are highly skilled and there is overwhelming evidence that better skilled nurses are better for patients, and reduce admissions, re-admissions and waiting times, free-up consultant’s, improve access to care, educate and share knowledge with other health and social care professionals and support patients in the community.


“Were there none who were discontented with what they have, the world would never reach anything better.”   

Fabulous Flo again.


Yup, I’m discontent Flo!  There are only 2 types of post-reg’ training programmes; Specialist Community Public Health Nurses and a Specialist Practice Qualification and for all practical purposes, degree entry-level.  We know they work (chronic heart failure for example and in Stoma nursing) so the default position should be; all patients, with long term conditions, should have access to a specialist nurse… but here we go again… there are not enough of them.


A new, free web-resource for Specialist Nurses caught my eye; help with job plans, annual reports and service summaries and I particularly liked the ‘Speaking up for my Service’ section.  I hope they and their managers do. 


“How little can be done under the spirit of fear.” More Flo truth-to-power-talk.


Nursing is the Swiss Army knife of the NHS; versatile, multi-purpose, portable, one-stop.  Nurses build, work and fix services, flex them and extend their reach and cover.  But, we patronise them and squabble over their numbers. 


“Let whoever is in charge keep this simple question in her head (not, how can I always do this right thing myself, but) how can I provide for this right thing to be always done?” Yes, Flo again… in full flow!


It looks to me very like nursing is in a muddle, confused, a jumble.  No one seems to have a clue what is ‘the right thing’, the right numbers or the right training.  Nursing, the biggest group in the NHS workforce, lacks direction… leadership.  Buried in directorates, managed by administrators shoved around by everyone’s agenda.   A Chief Nursing Officer (Carbuncle) and a Director of Nursing (DH), all chiefs but what about the Indians.


Events, technology, finance, balance sheets, bed-sheets, need and resources pull nursing in different directions.  The profession needs to stop, catch its breath and think about its voice, role and purpose.

I wonder what Flo would say? 

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.


Government, managerialism, leadership and poor care in the NHS

Today the government responds to the Francis Reports into the care failings between 2005-2009 at Mid Staffordshire NHS Trust. What can we expect?


I suspect that there will be a good deal of initiatives and new regulatory effort but little in the way of actual practical relevance.


In March 2013 the government published its initial response Patients First and Foremost in which David Cameron apologised to the families involved through parliament acknowledging systemic failures. It is to these systemic failures we must look to find some answers, but I suspect that my definition of a systemic failure may not be the same as Cameron’s. First lets consider where we are so far.


Jeremy Hunt’s foreword in March focused on creating a culture of safety, compassion and learning that is based on cooperation and openness. He identified four key groups who are essential in providing this culture:


  • Patients, service users, families and friends.
  • Frontline staff.
  • Leadership teams – Trust boards.
  • External structures: commissioners, regulators, professional bodies, local scrutiny bodies and Government.


The government’s response was, through the CQC, to appoint a new chief Inspector of Hospitals. Secondly, making hospital performance more transparent through a system of ratings. Then, something called a ‘single failure regime’. There would also be a Chief Inspector of Social Care. In addition the government would ‘foster a climate of openness’. How it would do that when it has no control at all over NHS organisations seems moot.


That was 8 months ago and so we cannot expect too much to change in a group of organisations that make up the NHS brand, a brand that is now a complex system of public and private provision distinct in organisational form from each other and from social care provision. What remains of the complex system is the underpinning Health and Social Care Act 2012.


Many of the 12 points in this March response are hard to critique, for example who does not want ‘Respect and Dignity?’ However there is a little nugget, point 8:


“We will work together to minimise bureaucracy, enabling time to care and time to lead, freeing up the expertise of NHS staff and the values and professionalism that called them to serve”.


This goes to the heart of the process of care, but there are no short cuts to doing this. Minimising bureaucracy requires leadership to address certain managerialist cultures. Prior to Mid Staffs, Leadership was seen as a key aspect of NHS culture changes. However, Leadership operates in certain organisational cultures and that rests mainly with management and can be strangled by a managerialist culture putting organisations into a catch 22: we need leadership to change cultures but we need culture change to allow leadership. However, it is bureaucratic management chasing non care oriented targets in order to maintain or gain Foundation Trust status which have distorted the care process and hampered frontline staff’s ability to deliver. This operates in wider socio-political context of the devaluing of care in that we accept the need for care but will not provide financial and social structures to allow it to flourish. Instead we have individualised care, leaving it mainly to families and women who are often provide it for free or for low pay.


Of the four groups identified above by Hunt, it is the leadership teams, especially hospital management and their Boards, which carry the most responsibility for care in NHS Trusts. Patients can exercise their voices, frontline staff can advocate or try to exercise clinical leadership, external groups can respond to failures often only after the event and were largely ineffectual as they may continue to be. Roy Lilley suggested that weighing a pig does not make it fatter – you have to build in quality from the outset, inspection is a post hoc activity. Trust Boards however set the tone and provide the resources and thus have the primary responsibility for the provision of good quality hospital care.  The Secretary of State for health has now abdicated that responsibility in an increasingly market driven health care system.


John Robinson, age 20, died in 2006 as a result of a ruptured spleen after a mountain bike accident. He was discharged from Mid Staffs Accident and Emergency department and died less than 24 hour later. A second inquest is being conducted. Caution must therefore be exercised in making any conclusions about the quality of care John received and whether it was in fact deficient. Claims regarding negligent care require certain conditions to be met and this has not been established in this case.


John’s parents claim that he was examined by a junior doctor, and that a consultant was not available. They suggested that if a more senior doctor had examined John then the chance of a ruptured spleen might have been considered. The junior doctor may have been incompetent, or she/he may have been acting within the limits of his competence, we do not know. The point however is that staffing of accident and emergency, and the training and development of staff who could spot this condition, are ultimately the responsibility of the Trust Board. Professional staff have a duty to make known their concerns regarding staffing and the competence of the team they work with, but they need the confidence to act on their concerns and the recognition by management that the exercise of clinical leadership involves challenging structures of support for clinical practice.


Therefore, professional staff have to be able to exercise clinical leadership safe in the knowledge that issues will be listened to and acted upon. However, managerial leadership may militate against this because their aims and objectives may blind them to real clinical needs. This was a criticism of Mid Staffs management.  In John’s case, if it was the poor decision making of an inexperienced junior doctor that was a major contributor to his death, we do not know if clinical leadership was exercised to address any issues of the training and support for junior doctors.


John Edmonstone (2008) suggested that clinical leadership is distinct from managerial leadership and is often ignored or not addressed by those considering leadership in the NHS. In addition he describes a disconnected hierarchy operating in health care organisations: a clinical hierarchy and a managerial hierarchy. This disconnect results in differing objectives, visions and ways of working. This is reflected by Robert Francis (2013 p3) who argued that the failings at Mid Staffs was primarily caused by:


“a serious failure on the part of a provider Trust Board. It did not listen sufficiently to its patients and staff or ensure the correction of deficiencies brought to the Trust’s attention. Above all, it failed to tackle an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities. This failure was in part the consequence of allowing a focus on reaching national access targets, achieving financial balance and seeking foundation trust status to be at the cost of delivering acceptable standards of care”.


Prior to this Hewison and Griffith, in 2004 argued, “too much emphasis on leadership without an equal concern for transforming the organisations (nurses) work in may result in leadership being added to the list of transient management fads”. Hewison in 2011 went on to argue that the focus on leadership as a solution to organisational ills remains in the NHS. This is rooted in assumptions that leadership, changing cultures and producing effective leaders will result in improvements in management and organisations. Hutchinson and Jackson suggested in 2012 that discussions around leadership often fail to address the issues of power, politics, dominance and resistance in organisational cultures. Both pre date Francis comments about the nature of Trust management at Mid Staffs.


Faugier and Woolnough (2003) provided some evidence of what organisations feel like to work in. and thus illustrate how management cultures can distort care practices. They describes three types of organisation:


  1. The Machine
  2. The Choir
  3. The Living organisation.


In their research 45% of respondents stated that their organisation felt like a machine in which leadership is generally driven by senior management to establish order and control. Strategic decisions are made through a formal planning process and change is planned and programmatic. Employees feel like a ‘cog in a wheel’. Faugier and Woolnough concluded that there was serious work to do to ensure clinical staff feel engaged and empowered. They argued that too many staff felt like cogs with high levels of disengagement and disillusionment and that that the implications for patient care were obvious. This was written in 2003, before Mid Staffs made the headlines. One can’t help but think that the antecedents for poor quality care were already established and were being written about for some time.


Questions remain: Will the government be able to do anything about how individual Trusts are run and financed? Will the frontline be properly staffed and supported; will they feel free to express concern about poor quality care?


Is clinical leadership any better supported, and will staff feel empowered and engaged? Will today’s government response address any of the fundamental issues?



Issues to address to address in this regard:


  • In a public sector organisation, clinical leaders cannot easily affect, or redefine public policy or legislation set by politicians and so they operate within the conditions set by others. Since the Health and Social Care Act Government has released the reins of control and conditions to NHS organisations and can no longer provide or dictate such issues as minimum staffing levels without enacting new legislation.


  • Nursing culture may inhibit clinical leadership development; issues of gender and medical power may continue to inhibit strong nursing leadership within Trusts and in clinical commissioning groups.  Has nursing got the respect of the public, politicians, policy makers and other professional groups to allow the to exercise strong leadership?


  • The focus on developing the person, their competencies and their traits, which are often based on male assumptions about what leadership looks like, may be in conflict with the exercise of leadership that focuses on relationships (shared leadership) within complex organisations.


  • The ratio of professional nursing staff to non-professional staff requiring training, supervision and regulation by clinical leaders is wrong. Not enough nurses, too many support staff.


  • Health care organisations may be risk averse and heavily regulated which counters leadership development that encourages risk and creativity and the challenging of the status quo.


  • Inspection and regulation are post hoc activities: are the CQC, Monitor and the Professional Bodies fit for purpose in terms of preventing poor quality care?

Too posh to wash? Failures of the governing, managerial and political classes

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.


Care quality in the NHS

.”‘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. The very structure of opportunities has collapsed. 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’. (p9). (C Wright Mills – The Sociological Imagination).

….today we hear about the safeguarding tragedy that was Daniel Pelka. Again, communication issues between agencies and the failure to act have been highlighted. His parents are in jail. If only one social worker failed then we should look to the character of that social worker. When we have a historical record of failures which all highlight communication issues and failures to act, we will not find solutions only in the failings of individuals, the socio-cultural systems itself fails. The correct statement of the problem and the the range of possible solutions require us to consider the economic, social, cultural and political institutions of society.

….we have heard about the care failings that was Mid Staffs. Again, neglect and abuse of frail elderly patients were highlighted. If only one healthcare professional or manager failed, then we should look to the character of that professional. When we have a historical record of failures which all highlight neglect and abuse, we will not find solutions only in the failings of individuals, the socio-cultural system itself fails. The correct statement of the problem and the the range of possible solutions require us to consider the economic, social, cultural and political institutions of society and not just the striking off professionals from registers.

Sir Brian Jarman stated in a recent Lancet article:

“To improve the quality of care in UK hospitals, I would reintroduce the Independent Review Panels and Community Health Councils and develop monthly complaints alerts similar to the mortality alerts. Regulation would be more independent if the CQC reported in public to Parliament, and there would be better communication if it were integrated with Monitor. Additionally, it is important to ensure  there are minimum staff-to-patient levels of doctors and nurses, with 65% trained nurses and  regulation of health-care assistants (my emphasis). I would aim for

total physicians per head of population at the EU average. Ideally I would also like to see training  introduced for the boards of trusts and for them to
have equal representation of patients, clinicians,  finance, and managers. There has been a decade  of concerns about the quality of care in our
hospitals: patients have been ignored, the  regulatory systems have failed, and there has been a culture of denial”.Instead we get the mess that is the Health and Social Act which is supposedly a ‘reform‘, and the NMC engaging in ‘re-validation’.

When will we learn that inspection and revalidation are external post hoc care quality issues, there is of course a place for these processes but there is a need to ensure the quality of care is structurally built into care delivery systems – and that means ensuring that you have enough staff, enough of the right sort of staff, educate and support them and engage in continuing professional development, appraisal and performance management if necessary.

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