Keeping the roar going

At the time of writing this post, the video of the poem by Molly Case that was read at the RCN Congress has been viewed 128,061 times in the 3 days since it was uploaded onto youtube.
I am not sure what constitutes 'going viral' but this must surely meet that criteria?

Twitter has been alive with Retweets of the link, and there have been several prompts by Tweeters to TV shows and other media outlets to get this video played to a wider audience.

What I find so incredibly powerful about this growing campaign is that it has motivated so many people to expand the influence of the message out of the circle of those who recognise the importance of the message, to those who might need some more convincing.

This message is one that many nurses already concur with, but preaching to the converted is not enough to really make an impact. Those that need to be made aware that the negative media focus on a small number of nurses is having a demonstrable effect on the remaining, dedicated and hard working members of our profession.
Morale in nursing must be at an all time low in the context of sustained criticism of the profession. How do nurses still manage to haul themselves out of bed to go to work when they know that there is a growing public perception that they have lost their ability to be caring?
Moreover, how are we going to continue to encourage people to come into the profession in the first place if this is how they are going to be perceived.

The professional identity of the nurse amongst student nurses (for those who know, or care) is the focus of my PhD, and I am watching these latest events very closely because- as the chinese would say- we live in 'interesting' times, and we can learn much from this.

But, this aside, there is a more pressing need for us now that we have this momentum. With International Nurses Day approaching, how can we keep the roar going?
How can we tell the world that, despite the revelations of the Francis inquiry, that nursing still holds great value to our patients; that if you want real change to happen in the NHS and beyond, that politicians and policy makers must listen to the next generation of nurses, our students.

I am incredibly proud of our students, they constantly surprise me with their enthusiasm and energy; they put up with a lot and they can be a great force for change. But we have to support them and give them the tools to turn this roar into action. 
There have been too many years of us just accepting that "this is the way things are" and that we just have to grin and bear it. Or, worse still, that if you raise concerns you will be ostracised.

Let's use the momentum gained from Molly's message.

Let's keep the roar going!

Deconstructing caring Part 1

Ask anyone (nurse or otherwise) to describe the essential attributes of the nurse, they will inevitably mention 'caring' at some point.
When interviewing for student nurses over the years we have asked the same question to the candidates on many ocassions, always with predictable answers. A nurse has to be caring.

It's a bit of a no-brainer isn't it?
Nursing is a caring profession, therefore to be a nurse you have to be caring. What's the fuss? Why even ask the question if it is implicitly understood to be the case? 
And you are probably wondering... why write a blog about it? 

Well, let me explain...

My PhD journey began in 2008, some 7 years after becoming a lecturer in nursing at University of West London. During those years I had resisted the idea of ever doing PhD. Having seen colleagues going through the hours of reading, writing and generally stressing about their research; culminating in a lengthy Viva Voce examination. 
The idea of the viva alone was enough to put me off. Having to explain, justify and defend your research's rigour for a prolonged period of time (in one case 5 hours!) did not appeal to me at all! Any exam that lasts longer than a Wagner opera is best avoiding in my world. 
Although I have subsequently learnt that this is an exception rather than the norm, I wasn't passionate about anything enough to warrant that level of commitment.
And after all, God doesn't have one!


At this time I shared an office with Stefanos Mantzoukas  (now Professor of Nursing, Ionaninia in Greece) who loved to discuss philosophy and nursing. Often at the end of the day we would kick back and bat ideas backwards and forwards about nursing and the nature of nursing knowledge. 
Actually, I make that sound like a great 'meeting of minds' when actually it was more like me throwing a half-baked theory at him and he then breaking it down and handing it back to me in all it's illogical incongruity. But I learned a great deal from him during these exchanges.

When Stefanos left to move back to Greece we kept in touch via Skype and email and would have similar discussions. During one such emaiI discussion I told him that I had been reading about Marx's theory of False consciousness and that it occurred to me that caring in nursing was something of a false consciousness; that the promotion of caring as being central to nursing care was potentially used as a means of restricting the profession from reaching its full potential at the heart of healthcare delivery, and that over the years nurses have been repressed by more dominant professions and policy makers because the primary attribute of the nurse was to exhibit caring behaviours and to be selfless.
Why have nurses not gone on strike in the UK to demand better resources to provide better care? Because, to walk out on your patients and to leave them to fend for themselves would appear to heartless and uncaring. An un-nursing thing to do.

The response from Stefanos was immediate... "I think that you are onto something there!", he said, and then added a note of caution "but of course, if you try and challenge the notion of caring in nursing, then you will be burned at the stake as a heretic!".

This was like a red rag to a bull. I was lucky enough to have been trained in a school of nursing that promoted the idea that we should challenge and question everything (quite progressive for the late 80's). 
I just knew that there was something to this, but couldn't quite comprehend what this meant? What was I really trying to say? That nurses shouldn't be caring? Surely that's not right! Uncaring nurses are not what we want to strive for!

Over the following weeks I got myself caught up in a complex network of conflicting ideas:
-Caring is about being compassionate, empathetic and kind.
-Nurses have to be caring for the well being of their patients.
-Caring is central to (and synonymous with) nursing which means that the nurses role is restricted to caring behaviours, which can put them in a powerless position to change healthcare delivery.
-How can all of this be reconciled?

Nurses who extend their role to be more proactive and autonomous in designing and delivering new services are sometimes derided by fellow nurses. The introduction of nurse prescribers was met with enormous resistance by doctors and nurses alike and took an inordinate amount of time to come into being. 
When you throw in the introduction of a UK wide adoption of undergraduate nurse education, then you can see why the idea that some nurses were "trying to be mini doctors" became a compelling argument from some corners.
Because, as this argument goes, nurses are meant to be caring and shouldn't have their heads filled with such ideas of grandeur.

So, I set about the task of trying to understand how nurses can improve their effectiveness as agents of change on behalf of their patients, whilst they remained incarcerated in the identity of nursing that society has constructed for them.

In part 2- 

I concede that I am going to need to do a PhD.... I discover that caring isn't what I thought it was... I find myself reading books by french philosophers!

I know why the caged bird sings

Twitter  has been alive with news and feedback from the RCN Congress for the past few days.

I can't think of another time in which there has been such mass communication about a nursing event, ever!

The advent of social media has transformed the way in which we relate to the world in which we live. So often now journalists are using Twitter to raise the profile of their stories to bring them into our consciousness. Moreover, accessing other Twitter users' messages to make sense of an evolving situation has also become commonplace.

So, the information coming out of the auditorium at the Arena and Convention Centre in Liverpool at this years congress has meant that I have felt very connected to the events as they occurred. Much of this has come from the 'force of twitter' that is Jenni Middleton, editor of the Nursing Times. Jenni's fingers must have been working almost non-stop!

Yesterday morning, as I was idly flicking through the tweets from Congress there suddenly came a veritable Tsunami of tweets about a student nurse named Molly Case, who had just read out a poem to the audience. Clearly, it had been well received as many tweeters had expressed great emotion as a result: "it made me cry" said one, "so proud to be a student nurse right now" claimed another.

To be honest, I have never been one for gushing sentimentality about nursing. That is not to say that I have been involved in desperately sad and emotional events as a nurse, but I have never been one for the whole poetic sentiment about nursing. For me, emotions are to be kept in check to remain professional and should not be allowed to flow uncontrollably.

A short while afterwards, thanks the RCN's live capture of the keynotes, a link to this poem started to circulate on twitter. I thought that I should take a look, just to see what all the fuss was about.

I was so moved by this, I was becoming quite emotional. By the time you get to the standing ovation, the hairs on the back of my neck stood up.

But this emotion, was also tinged with a certain amount of anger too. Because, in case you were wondering what Molly was referring to at about 2:40, when she talks about the 'Lip gloss-kissed women on daytime TV', she was responding to negative media coverage of nursing post-Francis. But more specifically she was pointing the finger at this:

This short piece on the ITV Loose Women show was just another public evisceration of student nurses for the delight of the daytime TV viewers. 

Leaving aside the specific comments made by these Loose Women, the power in Molly's poem came out of the anger and indignation that was evoked from yet another personal attack on the inherent values of student nurses.

It's a hard time to be a student nurse. As a school leaver with the qualifications to go to university you can choose from a whole range of academic subjects and career options. Nursing has battled against this for many years now. The options available to young people (male and female) are much greater. And whilst nurses salaries are relative better than they once were, there are still many options that will ultimately be more lucrative. So, as I have said before, you have to really want to be a nurse to do a degree in it.

But, there still seems to be a lengthening queue  of people waiting to accuse student nurses of not being "in it for the right reasons". And hence the anger.

The nursing profession is like a Pinata at a kids party: If you keep hitting it with a stick, eventually all of the goodies will drop out. And what you are left with is a beaten up old donkey.

Molly Case's poem was a polemic against this constant attack: "...we don't want the same tar-brush crushing our careers before they've even started" she pleads. And this is what made me feel so emotional. 

When I was a student, nurses were still seen in an almost saintly light. Now, they have to prove their worth to everyone, including our own profession.

This anger has to be turned to a positive though, and raising awareness of just how great our students are is the responsibility of qualified nurses, educators, managers and leaders everywhere. We can't just rely on students to fight this alone, they need our support.

After all, student nurses are OUR legacy to the profession.

Andrew Sargent

Who cares if nurses don't have a degree?

Once upon a time...

In 1873 an editorial in the British Medical Journal urged the readers to consider how the nursing workforce would be enhanced by the introduction of a professional certification and urged the newly formed schools of nursing to raise the standards of nurse education:

"... hospitals professing to 

train nurses must give a more thorough and systematic 

education. Not 

content with merely teaching them to dress a wound, put on a bandage,

or to deliver a woman-arts which require but a small amount of imitative

skill to attain unto-they must admit them to the lectures, to 

teach them the reason for 

and the value of what they do, so that in 

their sphere they be no automatic servants of,

but rational fellow workers w

ith, the physician."

What I find so interesting about this short passage is that, apart from the wonderful Victorian prose, it could have been written at any time in 140 years that have passed since.

What is this extract saying to us? That if nurses want to attain a status equal to that of the medical profession then they have to have a comparable education; an education that is based upon learning not just to do, but also to understand why you're doing it.

But it's funny how the idea that nurses and doctors could be considered equal in standing (although not necessarily doing the same job) is still a thorny subject, and often met with snorts of derision by members of both professions. 

As a newly qualified nurse in the early 90's I worked on a medical ward with a girl who had a nursing degree. She was the first such nurse that I had met with a nursing degree and I was slightly in awe of her. She was an exemplary nurse. She seemed so knowledgeable and had the most inspiring way of managing herself and the ward; and yet was kind and caring towards her patients. But, some of the other nurses were suspicious of her, feeling that she was "a bit snooty" and would tell me that she "thinks she's better than everyone else".

One one night duty I got talking to her about her nursing degree. Seeing that I was genuinely interested, she spoke at length about her course, the exams, essays and dissertation that she had to write. When I asked her about her experiences in practice placements, and whether she felt she was treated differently her face changed, she explained that most of these placements were "absolute hell". So, often she would go home from her shift in tears because she had been singled out for criticism where her fellow students on the certificate course had not.

It was made clear that her status as an undergraduate was interpreted as meaning that her practice had to be more advanced than than other students.

In a tutorial recently I was discussing what it means for nursing to be an all-graduate profession. Now, considering that all of these students were enrolled on a BSc(Hons) programme, you would be forgiven for thinking that there would be a consensus that an all-graduate profession is a good thing. But surprisingly, there was a large contingent of students who felt that the attainment of a degree was not essential to become a nurse, and that being caring and compassionate are the only essential pre-requisites for entering the profession. 

There is still a resistance and a deep suspicion in some quarters about nurses being educated to degree level, with the feeling that this might attract people into the profession who are intent only on 'collecting pieces of paper', without possessing the desire to care for their patients.

I have never really understood this argument. Surely, if your only desire was to get a degree then surely you wouldn't become a nursing student? The student nurse's life is hard by comparison to many other undergraduates.

As one student put it to me today "I feel like I have two masters, the university and the NMC". And this is a good point. Not only do our students have to fulfil all of the academic requirements of a Bachelors Degree, but they also have to complete the necessary practice hours; comprising weekend and night shifts. Furthermore, they are assessed on their practice whilst working. To survive the rigours of a BSc Nursing programme, you have to really want to be a nurse.

This is not a new issue and it is not going away any time soon.

The recent Francis report urged a reform of nurse education that would see potential candidates for nursing programmes to work as a health care support worker before being allowed to commence their undergraduate programme. This idea has been supported by Jeremy Hunt as a way for nurses to learn the core attributes of caring and compassion.

Not surprisingly, this idea has been met with resistance and anger. Today, it was cited as being unworkable and a waste of money by the RCN.

Another recommendation (183) proposes that "there should be an increased focus in nurse training, education and professional development on the practical requirements of delivering compassionate care in addition to the theory", and additionally that there should be a system in which a "selection of recruits to the profession who evidence the [...] possession of the appropriate values, attitudes and behaviours".

This is not only illogical but is also based on two erroneous and conflicting assumptions:

1) that caring and compassion are learned behaviours.

2) that caring and compassion are amenable to evaluation at the point of recruitment.

So, is caring and compassion learned? Can it only be learned in practice? Can you measure a person's caring and compassion?

There are divides in the debate about these questions. But clearly Lord Francis QC is sitting on both sides of the fence and has decided that you have to have it before you come into the profession AND you have to learn it whilst on the programme too.

But pointing the finger at nurses' caring and compassion is a bit of a cheap shot. It's our Achilles heel. We have spent so many years defending the caring and compassionate aspects of the nurses role that Caring and Nursing have become synonymous. 

But our insistence that nurses should be caring and not clever will only serve to destabilise our position. It is no big secret that there is an agenda to replace many qualified nurses with cheaper healthcare support workers. And if the logic holds that it is not necessary to have a degree to be caring and indeed that caring is an attribute that people have prior to becoming a nurse, coupled with the perception that caring and compassion are absent from the nursing workforce, it is only a small leap of faith to remove qualified nurses all together.

... and they all lived happily ever after?