Mike the Psych's Blog

What if psychologists ruled the world? In real life?

Nurses have no time for compassion

On the one hand the idea that all nurses are compassionate creatures was never true. I say that as someone with 20 plus years experience working in the NHS and more recently as a patient.

That’s not to say some, maybe most, nurses aren’t. I particularly remember one who held my hand throughout an uncomfortable 2-hour eye operation carried out under local anaesthetic and another who rubbed my back during an endoscopy examination.

But according to a recent study of professional values there is “a moral vacuum at the heart of nursing”.

Nurses are so ground down that they end up as “robots going through the motions” with a focus on clinical skills driving compassion from the job“. Yet compassion is part of the UK’s Nursing Vision.

Eight out of ten say their work conflicts with their personal values much of the time. The study concluded that it was that moral disengagement that leads to patients being put at risk.

Kristen Kristjansson, the psychologist from the University of Birmingham who led the study, said that the state of nursing was far more depressing than any other profession he had studied including lawyers, teachers, and doctors.

He added “When you have been working for five years or more you usually realise that following the rules is not the only important thing. You have to rely on your moral compass” But the nurses didn’t.

In the study of 700 nurses almost half of them sad they acted the way they did because it was what the rules decreed rather than because it was the right thing to do.

The only standard was what was laid down in the codes. Unlike other professions they did;t seem to pick up on their own values as they got more experienced.

This is bad news for patients who can tell when someone is going through the motions. The nurses say they don’t have time to show care and compassion and often come away from patients feeling they could have done more.

Professor Kristjansson worries that this “Mr Spock” mentality means they could struggle in a morally stressful situation such as happened at Mid Staffs where few nurses felt able to speak out about patient neglect.

He thought it was positive that nurses were now seen as a professionals requiring degree-level skills rather than just as assistants to doctors but felt the pendulum had swung too much the other way, away from the ethical core of nursing. Nurses since Florence Nightingale had done more than administer medicines – they created an ethos in hospitals to put patients at ease.

Sir Robert Francis QC, who chaired the public inquiry into the Mid Staffs scandal, backed up the Professor’s calls for more emphasis on virtue and character in nurses’ training.

A commonly accepted set of values has to be the foundation of professional practice to enable those with this vocation to navigate the ethical dilemmas they face daily”.

Janet Davies, chief executive of the Royal College of Nursing, said the report “demonstrates the emotional pressure on caring professions who, when faced with an inability to work as they know they should, become compromised”.

It’s almost five years since they decided to overhaul the training of health care assistants and introduced compassion as on of the 6Cs of nursing care (see post). Other research has shown compassion is a key characteristic of the best carers and there are questions about whether or not a degree  is really necessary?

It seems like we continually re-invent the wheel as far as nursing is concerned

The way things are going we will have fewer whistleblowers (not that the NHS has a good reputation for the way they treat such people) and the only way to wake people up will be another crisis.


A degree in nursing isn’t everything

nurse_figure_pushing_pill_1600_wht_14162The fact that nursing is now a graduate occupation doesn’t always mean that patients will benefit.

According to the Chief Executive at a London NHS Trust 1 in 3 of these graduate nurses are rejected because they fail simple numeracy and literacy tests. They have to pass tests in compassion (which is part of the UK Nursing Vision) as well but 83% of candidates from one London University failed in at least one of the three tests.

The tests are based on simple drug calculations which nurses need to know so that they can dispense medication safely.

The Chief Executive said that “while many nurses were well-trained and compassionate more should be done by universities taking responsibility for these basic skills and it should’t be left to the employing Trust to teach basic maths”.

At another London NHS Foundation Trust 15% of its nursing applicants failed similar drug calculation tests.

Dr Peter Carter, general secretary of the Royal College of Nursing said “modern nursing requires high standards in numeracy and literacy so it is vital that these skills are properly assessed at the recruitment stage”.

Professor Ieuan Ellis, Vice-chairman of the Council of Deans of Health which represents universities which train nurses, denied that graduates were ill-prepared for work on the wards. He said “UK data shows that between 81% and 100% go on to graduate=level jobs (and) if there was evidence of a widespread problem we’d be happy to follow it up but this view is simply not backed up by the data“.

Well it is at those two trusts and who do you believe, the employer or someone with a vested interest in running nursing courses?

The Sunday times gave examples of the test questions which are like these below.

  • A patient is prescribed 30mg of a drug which comes in 15mg tablets. How many tablets should the patient receive?
  • Another patient is prescribed 50mg of a drug which comes in 25mg tablets. How many should the patient be given?
  • A drug comes in 2.5mg tablets. How many would you give a patient who needs 12.5 mg?


NHS Déjà vu

nurse_icon_1600_wht_8175The good news is that plans have been put forward to ensure that all 1.3 million healthcare assistants will have to pass a basic skills test, a “certificate of fundamental care”,  before they can care for patients.

A review by Times journalist Camilla Cavendish following the Mid Staffordshire hospital scandal found that healthcare assistants spend more hands-on time with patients than nurses.

Her plan says that healthcare assistants should be called nursing assistants and be trained alongside nurses with mechanisms for getting rid of poor performers. They would also have a career path to allow the best of them to qualify as nurses without having a degree.

The Health secretary has ruled out full regulation so they wouldn’t be able to be struck off and the Royal College of Nursing supports some of the proposals.

Back in the 1960s there were two groups of general nurses. Student nurses who trained for three years and qualified to became State Registered Nurses (SRNs)and Pupil nurses who trained for two years to became State Enrolled Nurses.

In my local hospital you could easily tell who was who by the colour of their uniforms. Student nurses wore green and when they became SRNs they had a mid-blue uniform with a fancy belt and buckle (Sisters and more senior nurses wore dark blue). Pupil nurses wore purple and when they became SENs they wore brown uniforms. There were also cadet nurses aged under 17 who weren’t allowed on the wards who wore a pink or lilac gingham pattern uniform. Different hospitals had different colour schemes although mid-blue for SRN and dark blues for senior nurses was common. Nurse tutors sometimes wore maroon. You get the picture.

Then in the early 1990s it was decided that SENs should follow a conversion course to become an SRN as all nurses – SENs and State Registered Nurses (SRNs) – were required to train and convert to the new grade of Registered General Nurse (RGN).

Up to this point student nurses often lived in a nurses’ home in the hospital grounds and when they completed their training in the hospital’s school of nursing (a mixture of practical experience and classroom study) got a job at that hospital. When project 2000 came along that all changed – many would say for the worse. Nurse training was moved to higher education so that the students could obtain a diploma leading to a degree. Student nurses were educated in blocks of several weeks then sent out to hospitals in the region (not their local hospital) so they often found themselves travelling a long way to work. Not surprisingly drop-out rates were as high as 30%.

And on top of that they were only allowed to observe not actually get their hands dirty during their first blocks of work experience. Ward sisters were not happy about that as it created staff shortages on the wards. Previously student nurses were a key part of the team and a third year student was given a lot of responsibility. But in the drive towards making nursing an all-degree profession recruiters were looking for academic potential more than caring and compassion.

This lack of caring in nursing finally came to a head after a number of scandals in care homes and hospitals and this year the Chief Nursing Officer (CNO) Jane Cummings published a three year vision and strategy called Compassion in Practice setting out the values nurses should adhere to known as the 6 Cs viz Care, Compassion, Competence, Communication, Courage, and Commitment.