Why the quality of compassion may be too strained in modern nursing

Very occasionally something comes on the radio that makes you stand stock still in wrapt attention. It happened the other day as the Labour MP Ann Clwyd spoke about the death of her husband six weeks ago in the University Hospital of Wales in Cardiff. He died, she said, from hospital-induced pneumonia because “cold and callous” nurses did not keep him warm or care for him. “He died from people who didn’t care,” she said. The rawness of her grief burst the dam of self-control and she wept.

Earlier that day the Chief Nursing Officer for England, Jane Cummings, had called for nurses to focus more on compassion in their hospital care. That was what prompted Ann Clwyd to make her private grief public. “Nobody should have to die in conditions like I saw my husband die in,” said the doughty campaigner who was once her party’s human rights envoy to Iraq. “I have tried in the past to get bills through parliament on the welfare of battery hens. My husband died like a battery hen…. crushed against the bars of his hospital bed with an oxygen mask so small it cut into his face and pumped cold air into his infected eye”. Such treatment is now commonplace, she said, complaining of a “normalisation of cruelty” among NHS nurses.

Can this be true? The Government thinks so. The Health Secretary, Jeremy Hunt has been speaking of a “crisis in standards of care”. The scandal at Stafford Hospital three years ago, where hundreds of patients died after inadequate treatment, has now been followed by a Care Quality Commission (CQC) report which said last month that a staggering 27 per cent of hospitals and care homes are failing to meet minimum standards. In response the Chief Nursing Officer has called on nurses to focus on “six Cs”: compassion, care, competence, communication, courage and commitment.

Nurses, on their websites, are outraged. One talks of beds in her one-to-one care unit increasing from 9 to 15 with no increase in staff. Another says the ‘just-in-time delivery’ system of a service outsourced under privatisation left no clean linen available in her entire hospital. Another bemoans increased ‘efficiency’ in bed occupancy, with one patient moved in as another moves out, leading to patients discharged prematurely. Another criticises David Cameron for claiming the ratio of nurses to beds is rising without explaining there are fewer beds and more nurses are part-timers. Another reminds that the UK statistics authority has had to tick off Jeremy Hunt for claiming the NHS budget has increased when the reality is the opposite. Nurses offer their own list of ‘six Cs’ which includes cuts, contempt, crossness and crap. The beatings will continue until morale improves, one concludes bitterly

So who is right? Compassion is determined by two things: the way you are and the amount of time you have to spend. There is no doubt that spending cuts lessen the amount of time available for compassion; the more forms you have to fill, and checklist boxes you have to tick, the less you have for holding hands. But have our nurses changed the way they are?

Certainly their job has changed. Once nurses spent their first three years doing the washing, bum-wiping and basic health care now done by health care assistants. That early training taught nurses something about compassion or about themselves as they decided the job wasn’t for them. Today nursing is more medical and academic which self-selects a different kind of applicant. Nursing used to be an apprenticeship; now it’s more a course of study. Talking to patients has been replaced by communications training. Ironically training for doctors has gone the other way; once they didn’t go on the ward till they had three-and-a half years of book learning; now medical students are on the ward from year one. While they have been schooled to be less task orientated and more patient-orientated; nurses have gone the other way.  Making sure that someone is warm isn’t on the checklist.

The government speaks with a split tongue here. “They say they want more compassion,” one hospital consultant told me, “but they are very focused on us ticking all the boxes on the CQC guidelines, CNST guidelines and NICE guidelines”. Guidelines have become a self-perpetuating industry in which the tail wags the dog. “The law of unintended consequences is that the more rules you have to regulate care, the less caring people have time to be. All the onerous paperwork, the risk assessments and care plans, reward staff for the wrong things.” The nurse who does the job and forgets to tick is disciplined, the one ticks without doing it is rewarded unless a catastrophe finds them out.

The old-style nursing Sister is now a ward manager who may have zero patient contact. At the lower end of the nursing scale are increasing numbers of “bank nurses” – temps who are the equivalent of supply teachers in schools. “They don’t know the patients, the care plans, or where the blankets are kept,” another consultant said. “Wards are under-staffed, over-tasked and shorn of the time needed for compassion. Contrast that with private medicine – whether it’s a private consultant or a reflexologist, they spend time with you. You don’t feel rushed; you get an hour, not five minutes for the consultation and three to fill in the paperwork afterwards.” That is why one Care Quality Commission report found that cleaners had more time than nurses for small acts of kindness, like cleaning an old lady’s spectacles.

Yet Care Quality Commission inspectors say they see unacceptable care on well-staffed wards, and excellent care on understaffed ones. Good hospital management ought to be able to address that issue. Yet the more senior managers the NHS has – 40 years ago it had just 500 compared to 70,000 today, increasingly recruited from outside the health service – seem to spend their time sending out emails about “Quality” issues when, as one nurse put it, “the wheels on the bus are flat and the engine is out of oil”. The Care Quality Commission suggestion that potted life stories for each patient should be given to nurses (who should be forced to spend time on every shift discussing patient feedback) will only shrink the time staff have for acts of compassion even more. The problem at Stafford Hospital was that senior managers put cost-cutting and Government targets before care. All the guidelines were fulfilled but hundreds of people needlessly died.

More managers? More targets? Insanity, Einstein is alleged to have said, consists in doing the same thing over and over again and expecting different results.

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