NHS nurses: saints or sinners?
Nurses are the heartbeat of the NHS, but does that excuse them from blame?
In the context of Danny Boyle’s recent paean of praise for the NHS I would like to tell a little story. Recently my elderly and frail Father was admitted to an East Anglian hospital. As a former NHS hospital manager I witnessed his final hospital stay from the other side of the bed so to speak and the scales fell from my eyes. I realised that the biggest villains in the deterioration of care standards and the explosion of useless mouths in the NHS are actually the very people whom Joe Public would regard as helpless angels and put-upon victims of bureaucracy – Nurses.
Now bear with me through such an unpopular take on the travails of the NHS. I do not refer to those individual nurses whose caring, skill and, yes, love make them precious adornments to the human condition, but their numbers are in decline. I refer to the corporate nurse.
For the corponurse the power of the profession is all. They talk of being the patient’s advocate, using this exalted self-appointed status to bolster their corporate position. They invent policies, procedures and protocols which proper nurses must adopt on pain of professional execution.
Corporate nursing has caused a degeneration of professionalism despite giving the appearance of seeking the opposite and has inculcated a professional absolutism in which good standards die.
When did NHS nurses take to automatically calling all their elderly patients "darling" or "lovey"? When did they start running around the ward? Who taught them to speak so loudly that everyone within 100 yards knew of every bowel movement? When did they preface every answer to a reasonable query with, “Well we’re very busy you know”, neatly making you part of the problem and absolving them from finding a solution? This is unprofessional grandstanding.
Above all when did they start wasting so much time in form filling? They write copious notes of every conversation, intervention and bum-wipe. Incidentally, these notes go into the file and are never ever read again by anyone except the nurse on the next shift, who repeats the process.
This is not another example of evil bureaucracy imposing on nurses. They have invented all this rubbish themselves. I suppose I should have raised these issues a long time ago and I am ashamed that I didn’t, but in the last great Stalinist command economy in Europe you don’t rock the boat.
The rot set in during the seventies when the Salmon report recommended a new career structure for UK nurses; I’m not sure what was wrong with the old one – Staff Nurse, Sister, Matron, seems simple enough.
Over 40 years nurses created and re-created a professional structure which neatly missed the point that their power was always vested in the ward sister and the matron. Even Sir Lancelot Spratt wouldn’t argue with a good ward sister and certainly not with the matron.
We have ended up with students, staff nurses, senior staff nurses, charge nurses/sisters, senior sisters, modern matrons, departmental matrons, assistant Directors, Directors and a whole host of specialist practitioners and liaison support nurses. Call that a structure? It’s a bureaucracy.
They have invented warehouse scale form and reporting libraries and guard all these systems under the mantra of "safety". Anything that nurses don’t want to do becomes "unsafe".
Reduce shift changeovers by 5 minutes? Unsafe. Forget about staffing ratios during a major incident? Unsafe. Any change, any threat to their administrative position, any criticism of a bureaucratic idiocy – all unsafe - and it’s all nonsense.
Some time ago I attended a conference on the barriers to effecting early patient discharge. The solution, you may be surprised to know, is a form. One nurse presenter proudly announced that in her hospital every patient medical record file had a "Date For Discharge" form.
I asked her afterwards how many of these forms had discharge dates written on them. She didn’t know. How many of these patients were actually discharged on those dates? She had no idea and no way of telling that didn’t involve appointing more nurses to do the checking. So the answer to this and to so many other problems, is to put a piece of paper in a file.
I could never get used to this sort of NHS bureaufest which burnt me out some time ago and I now work in a much more patient-centred and accordingly more successful, happier organisation.
Suppose for a moment, that you’re an aspiring staff nurse. You may work your way up the clinical pole. But, if you take a job as Quality Co-ordinator you’ll be made. You’ll soon find yourself inventing and enforcing the standards which require all these forms, people, reports and meetings. Before long you will be snapped up by a Consultancy company or even set up your own; and then the World’s your oyster. That’s why so many health sector quality professionals are ex-nurses.
The nursing profession is the most important vector of NHS bureaucracy. They are perhaps unchallengeable. Maintaining good care, however, is not rocket science.
There are about five key standards against which hospital managers of all professions should be measured and their remuneration and continued employment decided. Is the hospital or institution clean? How many patients acquire an infection? What percentage of patients are treated as daycases? How many are re-admitted with the same condition within two weeks? And finally, what proportion take successful medical negligence claims? These are standard, internationally-recognised measures.
The old fashioned matrons and sisters had authority born of vocational standards and the new ones simply don’t. As for my Dad, a lifelong NHS supporter, we rebelled and insisted on taking him home where he died warmly and quietly in the bosom of his family. I regard this action of removing one sick old man from the clutches of ‘the system’ as the pinnacle of my NHS career. Now that’s sad.
Jim Corbett was an NHS manager for 20 years and has written many articles for the Health Service Journal
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