Can nursing care ever be 'basic'?

This is a collaborative blog post by:
Andrew Sargent - Tutor and PhD student at King's College London
&
Charlie Johnston- Student Nurse at University of Lincoln

We have both made a few observations on this question below.

Andrew Sargent:
There is a lot of talk about student nurses doing a year of work as a Healthcare Support Worker prior to commencing their studies, to learn 'basic nursing care'. 
This of course comes from the Secretary of State for Health, Jeremy Hunt in response to one of the recommendations of the Francis Report.
Naturally the idea has been met with much resistance and has invoked a great deal of debate.
This issue aside, there is a more pressing question that needs to be asked here; what is 'basic' nursing care?
This question has been asked before the recent events surrounding the Mid Staffs Inquiry. I am aware of the term being used for some years now. I have in the past (very politely) reprimanded students and colleagues that have referred to some aspects of nursing practice as basic. 
Take hygiene as an example, if you are assisting a bed-bound patient with hygiene needs there are a whole range of knowledge and skills needed:

• Assessing the patient's self-care deficit (How much or little are they able to do for themselves)
• Involvement, willingness and consent of the patient.
• Consideration of the limitations involved (dressings, wounds, prostheses, range of limb-movement, equipment attached to the patient etc)
• Identification of equipment required (are there special considerations re soaps or cleansing products)
• Evaluation of skin integrity (wounds, sores, infections, allergies)
• Knowledge of skin physiology (identifying areas of potential damage).
• Awareness of issues around surgical wounds and dressings.
• Dignity, privacy and individuality.
• Communication before, during and after the procedure.

I could go on... but I think that you get the idea. There is more to this than just flicking a wet cloth around. Furthermore, the procedure of being with the patient is an opportunity to assess other care needs, evaluate current care implementation and to discuss any issues that the patient needs to talk about.

In short, there is a whole range of skills, knowledge and behaviours that are required by the nurse; there is nothing 'basic' about nursing. Nursing requires an in depth knowledge of many subjects and also requires interpersonal skills to ensure that the care is Person-centred.

So, why do we refer to any aspect of nursing care as 'basic', why are some advanced skills demeaned with this terminology? 

It's tempting to say that there is an underlying agenda to divest some of this important work to unqualified (and cheaper) HCSW's as a cost-cutting exercise. After all, Nurses are expensive!

I wouldn't like to say that this is necessarily the case, but by altering the language around certain nursing skills (by relegating it to that which would seem to be achieved equally well by non-professionals) does nothing to promote the importance of having a higher number of experienced, qualified nurses in clinical practice.
(AS)

Charlie Johnston:

We must be very careful when applying terminology to the care we provide. On the whole, I believe the term “basic” isn’t being used to deliberately devalue the care we provide in any way, but more to effect of describing the very minimum that we must get right. However, I feel the word “basic” invokes the idea of a set of instructions or tasks that anyone can achieve with relative ease, and of course, most people probably could do so. 

For example, the above points by Andrew demonstrate the thought process that one must apply when performing personal care. If we were to take the first 7 steps and work through this list then the task would have indeed been completed. But when we think about our role as nurses there is and should be much more to it that that. That interaction with the person may be their only and therefore most important interaction of the day.

Essentially it’s fundamental to that person’s experience and I feel, to describe such an important aspect of someone's care as “basic” almost infers that they are low on a list of priorities which I feel only serves to devalue that person to us, which of course, when aiming to provide person centred care, should never be the case.

This is where the implementation of the last 2 steps become very important and prove that such care is not “basic”. It is these 2 steps which are the essence of nursing and create a good patient experience.

It is the untangible, the identification of the nuances of each and every person and the tailoring of such care to each. This, to me, is not “basic” but important. It’s what gives us the ability to touch lives and for me at least..and I know I speak on behalf of many wonderful nurses...it’s fundamental.

  

Just a few more ramblings on Jeremy Hunt and his idea of introducing a minimum period of work as a HCA before applying to study Nursing. Overall, I think I sit on the fence. Despite my initial reaction of mutterings that are probably best to avoid publishing, I now sit on th fence. I can see why Mr Hunt believes his idea is a good one and indeed it would open a few eyes of those who lack experience. Agreed. But on the otherhand, I fear that it would become little more than a hoop to jump through and possibly, I worry anyway, that it could create the idea that performing such work and fulfilling the role is little more than a stepping stone onto bigger and better things?

(CJ)

We would value any thoughts and comments that you have on this subject. Please feel free to use the comment box below.

Andrew Sargent & Charlie Johnston May 2013

Nurses aren't caring for their patients

Deconstructing Caring part- 2

The great thing about my job is that I get to talk about nursing all the time. This might be in the classroom, or in the many tutorials and meetings that I hold with students.
At other times I inevitably will be discussing aspects of nursing and education with my colleagues. This is something that I find particularly interesting.
So what do I do in my spare time?
Well, my PhD occupies a lot of my mindspace most of the time; it is hard to escape this as I am constantly thinking about how I am going to translate all of these random thoughts into some kind of meaningful discourse in the form of a thesis.
I am also married to a nurse (well actually she is a manager in the health service but she is a nurse at heart still), so we do discuss various aspects of each other's work and other issues in the news.
Don't get me wrong, I am interested in other things too. And being parents of 2 teenagers, we do have to change the record some times.

So, making the transition into being a PhD student was a fairly natural process. Once I had decided that my ideas about caring might make an interesting research study (see Part 1) I suddenly found that I could make some use of these ideas buzzing around in my head.

Over the years I have learnt that there is much more to being a nurse than just to be kind and caring. You can get by with a little learning, but it has only been since I jumped on the ladder of education that I have really come to appreciate the complexity of nursing and the true nature of what it means to be a professional nurse in the 21st century.
You see, caring is something that we intuitively feel that we understand, even though we have great difficulties trying to articulate exactly what it is.
Caring has only been in the nursing lexicon since the mid 20th century. And the notion of compassion has received very little attention until very recently. That is not to say that nurses never used to care about their patients, but any historian of nursing will tell you that the context of care delivery was very different in the first half of the last century. Nursing then was more about duty and vocational devotion to the sick. The idea that nurses could be considered to be professionals created great conflict and vociferous debate before, during and since the passing of the Nurses Registration Act of 1919. Even Florence Nightingale held deep reservations about the professionalisation of nursing.

Enough history... what I am trying to say here is that the caring discourse has become a very naturalised form of language in nursing. So much so that to say that what nurses do is NOT caring is to commit an act of heresy. 

I once began a lecture to 300 students thus:
"Nurses aren't caring for their patients. They never have,and never will. Caring is not what nurses do".
Stunned silence and some rather shocked looks followed.
I let that sentence hang out there for a few seconds to let it sink in, then followed up with,
"of course, nurses care about their patients, and hence we could describe nurses as being caring. But what nurses do, is not caring. To say that would be to simplify a complex range of skills, knowledge and behaviours that are required to practice nursing, into a vague and ambiguous term.".

The reception to this was actually very positive, once people got what I was trying to say. Because, once you start digging around the concept of caring you find that you enter a very strange and ambiguous world. In our desire to make caring a science (and thereby raise the discipline of nursing to something more empirically based) some inconsistencies emerge.

If caring can be measured, predicted and modeled (as is required of scientific knowledge) then we have to decide what caring is; what is included in the concept? To do this, many authors set about performing concept analyses and what they ultimately concluded was that just about everything that nurses do are included within the concept. 

Hence: Caring = Nursing 

In other words, caring (the verb) and caring (the adjective) became enmeshed. But this is illogical both grammatically and theoretically. To be caring you don't have to be a nurse. Likewise, to do caring is not the exclusive domain of nurses either. 
However, to be a nurse you do have to be caring.

So, if we take caring in it's purely adjectival meaning to represent the desire to have genuine concern for the wellbeing of our fellow man, then that clearly underpins everything that nurses do. It is an ontological position out of which action arises.
This would include tasks like paperwork and other non-clinical roles, because the bottom-line is that these things will eventually lead to some positive benefit for our patients. 
But caring only underpins nursing, it is a foundation block but it is not an adequate descriptor of the totality of the nurse's role. 
To be a nurse you have to have a wide range of skills, knowledge, experience and self-awareness; all of which can easily sit outside of being caring. They are mutually exclusive.

Underneath the most beautiful building is a mass of concrete and steel that forms its foundation, without it the building could not stand upright. But to describe the building to someone you wouldn't say that it is a mass of concrete and steel, you would instead talk about  the beauty of the building itself. 
Caring is what we are, not what we do.

With this in mind I set about backing this up by getting my ideas out into the academic world and my first paper was eventually published in print last year.
I was very nervous about how it would be received because I was aware that it could be very easy to misinterpret what I was saying and make it sound like "nurses don't need to be caring". Playing into the "too posh to wash" brigades hands.

I needn't have worried. On the back of this publication, I have received positive and encouraging emails from all over the world. I was even invited to present some of my work in the USA, Australia, Canada and Germany.

In this paper I began to deconstruct caring as a central and defining concept in nursing. Not for any malicious or antagonistic agenda, but just as an opening gambit to emancipate the complexity of nursing practice from being confined to one simple defining word. A word that is ubiquitous and not unique to nursing.


(as always... my opinions are expressed here only)

Student nurses are instruments of cultural change

On Wednesday evening a packed Edmond J Safra lecture theatre King's College London heard the inaugural lecture from Professor Jill Maben titled "Care, compassion and ideals: nurses experiences of nursing". Jill is the Director of the National Nursing Research Unit at King's and is a well respected researcher of nursing. She also just happens to be my PhD supervisor.

I won't recount the entire lecture, hopefully at some point a transcript will emerge because what Jill presented to us were the key research projects that she has undertaken over the last 16 years. All of which are surprisingly resonant in the context of the Francis Report.

Reference was made to Austin Thomas's excellent speech at the RCN Congress last week, where he spoke of his experiences of being nursed during his 30 operations, following a motorcycle accident. Austin had spoken of the nursing staff as 10% bad, 10% good and 80% indifferent due to 'care fatigue'.
I wasn't in the audience at congress when this was stated, but I can imagine a collective sharp intake of breath in the auditorium by some, and nods of agreement from others. I would have put myself in the former category had I have been there instead of having watched the webcast.
When we nurses talk about nursing these days, the image of the nurse seems to fall into two categories:

• Nurses are failing in their duty to care for their patients and lack the core values that we have traditionally associated with the profession.
• Nurses are caring and compassionate by the virtue that they have chosen this career but are operating within organisational constraints that prevent them from doing what they know is right for their patients.

The implicit assumptions that underpin these two opposing views of nursings professional identity are that nurses either come in to the profession with the wrong values and they do not attain them whilst students, or that nurses our powerless to be the type of nurse that they wish to be.
Internal locus of control in the first, external locus of control in the second.

Professor Maben feels strongly that nurses do come into the profession with the right ideals and values for nursing, and that the sustainability of these values is dependent on the culture in which students and professional nurses find themselves working. The culture on the wards and in the environment in which the nurse finds themselves will correlate with the fate of the nurse's values and ideals. 

Furthermore, she found in her doctoral research that there were certain 'covert rules' within nursing culture that would affect the developing identity of the nurse. These covert rules included 'getting the work done' (focusing on tasks that have to be achieved in the working day rather than being patient-centred), and 'not rocking the boat' (accepting the way things are and not 'creating a fuss'). 

The first of these covert rules reminded me of a morning shift that I did on a busy acute medical ward as a first year student. The ward was run by a formidable but inspirational ward sister. I had been allocated to care for a group of 5 patients, most of which were 'self caring' and one who needed full assistance with hygiene  We all set about our tasks of ensuring that our patients were washed, dressed and sitting out of bed. I was having one of my super-efficient days and by about 10am all of my patients were sitting in their chairs looking clean and fresh. Being keen to impress the Sister and to get a good ward report I cheerfully informed her that my work was done, to which she paused momentarily and said "hmm.. you've finished have you? Is that all that nurses do? Wash and dress patients?".

Of course, I realised straight away that I had made the error of conforming to the idea that nursing is only about getting tasks done and that I had overlooked the fact that the patients were not just here for the benefit of giving me something to do. I didn't have a clue what my patients actual needs were beyond the task of washing and dressing. 

"Go and talk to the patients to find out what their needs are, then come back and tell me that you have done your work!".

Feeling somewhat chastened I duly went off to talk to each of my patients. I found out about their medical conditions, their treatments, what they were feeling and were afraid of, how they felt about what was happening to them and what the future held. By the end of the shift, I really felt that I knew about the scale and complexity of the patients' needs and (although I didn't yet have the answers) what they needed to have put in place for them.

I had conformed to a previous role of being an auxiliary nurse in which my primary purpose was to get the jobs done. A role in which there was no real requirement for me to do anything other than washing and dressing.

When time is short, resorting to this task-orientated approach to nursing is commonly observed. Just get the jobs done and if there is time left over, then you can look and see if there are other needs that have to be met. 

I was lucky enough to have been in on a placement where the culture actually valued nurse-patient interaction as a means of identifying patients needs. To sit with a patient to talk to them was not seen as slacking-off, but as nurses doing what nurses should be doing.

Sadly, a few years later I bumped into the Sister in town, she told me that she had left nursing as she could no longer find the energy to deal with the stress of providing care for her patients and that financial and staffing constraints were reducing her ability to be compassionate.

The culture on that ward opened my eyes to what nursing can, and should be. I wonder if I hadn't have had that experience how it might have shaped my identity as a nurse? I wonder if I would have become a functionally competent but emotionally disconnected nurse?

The covert rule of not rocking the boat is one that really concerns me. The obvious sequlae of this would lead to a situation like the one that was revealed at Mid Staffs NHS Trust. But I worry that this is only a part of the story. Yes, we all look at the Francis Report and shake our heads at just how bad situations can get when staff concerns aren't heard. This is a high profile indictment of a failing organisation. But, before you get to a problem of that magnitude there will be a slow, steady erosion of the organisational culture. And that starts more locally; within individual teams on individual wards and units. 

Students have come to me in the past to express concerns about things that they have seen in practice. Often, these are not cases of negligence or professional incompetence that have formal routes for reporting. More commonly these situations that are intangible and hard to articulate. To raise them as problems might seem to be an overreaction on the part of the student, and might lead to the student to be labelled as a troublemaker or 'a bit precious'.

I always try and get the student to explore what it is that has made them feel uneasy about the situation. I ask them which of their values and ideals are being challenged by what they have seen or heard. However, when I suggest that they raise these concerns with their mentor in practice I inevitably get the same response, "I don't want this to affect my assessment in this placement", and often they decide to keep quiet and just see out the rest of the placement.

Yes, some students will not necessarily make complete sense of what they are seeing or understand all of the factors that influence some of the situations that they find themselves in. But that doesn't mean that they shouldn't be listened to. After all, you could say the same about patients but that doesn't stop us from actively asking them about their experiences of the care the receive. 

If for example, a student hears a nurse speaking about a patient in a way that overlooks some important aspect of their care needs that the student feels should be considered, what is the student to do? The easy answer for us, as registered nurses is to say that they should speak up. But students often find this very difficult to do. Some students have said to me that before speaking up they would need to be able to articulate their point well otherwise they might be put down as not knowing what they are talking about, or feel that they are being difficult.

Cultural change in the NHS has been a major focus of the Francis report recommendations. But culture in the work place is not ubiquitous and is complex and context dependent. There is not a one-size-fits-all method of changing culture. We have to start by changing culture locally first it seems.

I believe that students can, and should be at the heart of changing the culture in practice. They are still learning but they can offer insights into practice that they have accumulated from recent experiences on other placements and from their learning in university. Students are just full of ideas and insight. So much so that they are nearly fit to burst sometimes!

Instead of just teaching them and signing off their competencies, perhaps we should be actively asking for their thoughts on patient care and actively involving them in the future direction for providing that care. When this happens the students benefit from being taken seriously, the ward/practice area benefits from developing a more fluid and dynamic attitude to nursing, and ultimately the patients benefit from a workforce that is constantly trying to change and improve in response to patients needs. 

We should allow students and nurses to rock the boat and give them a platform for challenging practice.

If their perspectives are wide of the mark then that is a good opportunity for their learning, if there is some validity in what they are saying, work with them to find ways of changing practice. But the first thing to do is to listen.

Professor Maben's work highlighted that the fate of nurses' ideals and values as being either sustained, compromised or crushed. The figures of which appear to correlate with Austin Thomas' 10% bad, 10% good and 80% indifferent. She concluded by suggesting that our efforts should be focused on the 80% indifferent rather than the 10% bad. If we can change the culture to encourage and motivate the 80% then suddenly these figures look more like a 90%/10% split, which is a very good start indeed!




(My own opinions expressed here, not necessarily anyone elses!)